Medicine, health and Irish experiences of conflict, 1914–45 9781526108227

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Medicine, health and Irish experiences of conflict 1914–45

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Medicine, health and Irish experiences of conflict 1914–45 Edited by David Durnin and Ian Miller

Manchester University Press

Copyright © Manchester University Press 2017 While copyright in the volume as a whole is vested in Manchester University Press, copyright in individual chapters belongs to their respective authors, and no chapter may be reproduced wholly or in part without the express permission in writing of both author and publisher.

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Published by Manchester University Press Altrincham Street, Manchester M1 7JA www.manchesteruniversitypress.co.uk British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data applied for

ISBN 978 0 7190 9785 0 hardback First published 2017 The publisher has no responsibility for the persistence or accuracy of URLs for any external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

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Contents

List of figures List of tables List of contributors Acknowledgements

page vii vii viii xii

Introduction David Durnin and Ian Miller

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Part I: Health and disease on the domestic front   1  ‘Every human life is a national importance’: the impact of the First World War on attitudes to maternal and infant health Fionnuala Walsh

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  2  The war and influenza: the impact of the First World War on the 1918–19 influenza pandemic in Ulster Patricia Marsh

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  3  Food, the Emergency and the lower-class Irish body, c.1939–45 Bryce Evans   4  Alone among neutrals: Ireland’s unique experience of tuberculosis during the Second World War Anne Mac Lellan

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Part II: Health and political unrest   5  War on our doorstep: Temple Street Hospital and the 1916 Rising 81 Barry Kennerk

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Contents

  6  Ireland’s British Army doctors and the treatment of Irish nationalists, 1916–23 David Durnin

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  7  The ‘report of a nightmare’: hallucinating conflict in the political and personal frontiers of Ulster during the IRA border campaign of 1920–22 Fiachra Byrne

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Part III: Institutions and medical personnel   8  From front to home and back again: geographical networks of auxiliary medical care in the First World War Ronan Foley

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  9  Hope and experience: nurses from Belfast hospitals in the First World War Seán Graffin

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10  War work on the home front: the Central Sphagnum Depot for Ireland at the Royal College of Science for Ireland, 1915–19 Clara Cullen

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11 On the brink of universalism: the Emergency Hospital Services in Second World War Northern Ireland Seán Lucey

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12  Imperial continuities: Irish doctors and the British armed forces, 1922–45 Steven O’Connor

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13  Migrants, medics, matrons: exploring the spectrum of Irish immigrants in the wartime British health sector Jennifer Redmond

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Index

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Figures and tables

Figures 4.1  Tuberculosis mortality in Europe, 1938. Source: M. Daniels, ‘Tuberculosis in Europe during and after the Second World   War’, British Medical Journal, ii (12 November 1949), 1065–72, 1066 page 64 4.2  Tuberculosis mortality in Europe, 1946. Source: M. Daniels, ‘Tuberculosis in Europe during and after the Second World War’, British Medical Journal, ii (12 November 1949), 1065–72, 1067 65 8.1  Geographical Distribution of Auxiliary Therapeutic   Network in the First World War (1914–19).   Copyright © Open Street Map/CC-BY-SA 130 Tables 1.1  Infant mortality rates in Ireland and Great Britain (1910–20) page 24 1.2  Comparative urban infant mortality in Dublin, Belfast, London   and Glasgow (1912–18) 25 4.1  Deaths from tuberculosis in Ireland (1913–20 and 1938–48) 62 4.2  Deaths from meningeal tuberculosis in Irish children (1938–50) 66 6.1  Salaries for medical officers of the Irish National Army   Medical Corps (1923) 105 12.1  Father’s occupation in interwar cohorts 194 12.2  Father’s occupation in wartime cohorts 199 13.1  Occupations of Irish citizens in the British medical field 209 13.2  Occupations of Irish men in medical-related professions 210 13.3  Occupations of Irish women in medical-related professions 211

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Contributors

Fiachra Byrne is a postdoctoral research fellow at the Centre for the History of Medicine in Ireland, University College Dublin. His current research project is on the mental health of juvenile prisoners in England and Ireland from 1850 to 2000. This forms part of a wider research project, funded by a Wellcome Trust Senior Investigator Award, led by Professor Hilary Marland (University of Warwick) and Dr Catherine Cox (University College Dublin) entitled ‘Prisoners, medical care and entitlement to health in England and Ireland, 1850–2000’. Clara Cullen  is a former academic librarian whose research centres on the history of cultural institutions in nineteenth- and twentieth-century Ireland. As well as her recent publication,  The World Upturning: Elsie Henry’s Irish Wartime Diaries, 1913–1919  (Merrion, 2013), she is a co-editor of  His Grace Is Displeased: Selected Correspondence of  John Charles McQuaid  (Merrion, 2012) and The Building of the State: Science and Engineering with Government on Merrion Street (University College Dublin, 2011). Clara has published contributions in J. H. Murphy (ed.), The  Oxford History of the Irish Book Volume Four (Oxford University Press, 2011); D. S. Andriolle and V. Molinari (eds),  Women and Science, 17th Century to the Present (Cambridge Scholars, 2011); J. Adelman and E. Agnew (eds), Science and Technology in Nineteenth-Century Ireland  (Four Courts Press, 2011); D. Raftery and K. Fischer (eds), Educating Ireland: Schooling and Social Change in Ireland, 1700–2000 (Irish Academic Press, 2014); and Brendan Walsh (ed.), Knowing their Place: The Intellectual Life of Women in the 19th  Century  (History Press Ireland, 2014).  Her forthcoming publications include  Jones  125: A Dublin Engineering Company Breathing Life into Buildings since 1890 (Jones Engineering Group, 2015) and ‘A Veritable Genius’: Sir Robert John Kane in Nineteenth-Century Ireland  (Irish Academic Press, 2016). Clara is

List of contributors

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an associate of UCD Humanities Institute and the 2013 winner of the Royal College of Physicians of Ireland History of Medicine prize. Clara would like to acknowledge the UCD Humanities Institute. David Durnin is an Irish Research Council Government of Ireland postgraduate scholar at the Centre for the History of Medicine in Ireland, School of History, University College Dublin. His research examines Irish medical involvement in the First World War. He is the winner of several awards in the history of medicine, including the History of Medicine in Ireland Prize and the Royal College of Physicians of Ireland History of Medicine Research Award. Bryce Evans is a lecturer in history at Liverpool Hope University. He specialises in twentieth-century Irish history and comparative national economic histories of the Second World War in addition to food and resource history. He is the author of three monographs on modern Irish history as well as numerous peer-reviewed research articles and edited volume contributions. Ronan Foley is a lecturer in the Department of Geography at Maynooth University. He is the author of Healing Waters: Therapeutic Landscapes in Historic and Contemporary Ireland (Ashgate, 2010) and carries out a range of research on health, place and water. He was appointed editor of Irish Geography and completed the chapter in this volume while an Erskine Fellow at the University of Canterbury in New Zealand in early 2015. Seán Graffin is a qualified lecturer in nursing at Ulster University. Seán is currently pursuing a Ph.D. relating to the history of medicine in which he explores the development and professionalisation of nursing in Northern Ireland in the late nineteenth and early twentieth centuries. Barry Kennerk works at Temple Street Children’s University Hospital, Dublin where he is resident historian and archivist.  To date, he is the author of four critically acclaimed books and a number of peer-reviewed articles on topics including the history of Temple Street, the treatment of gunshot wounds in nineteenth-century Ireland and leading Irish medical figures including neurosurgeon Adams Andrew McConnell and Thomas More Madden. His work has featured in Social History of Medicine, Journal of Medical Biography and British Journal of Neurosurgery.  He is currently undertaking a postgraduate degree in archival studies at Aberystwyth University, Wales. Seán Lucey is a historian of modern Ireland and Britain with expertise in medical and social history. He has held academic positions in Queen’s University Belfast, University College Dublin, Trinity College Dublin and Oxford Brookes University. His most recent monograph is entitled The End of the Irish

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List of contributors

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Poor Law? Welfare and Healthcare Reform in Revolutionary and Independent Ireland  (Manchester University Press, 2015). Other publications include (coedited with Virginia Crossman)  Healthcare in Ireland and Britain from 1850: Voluntary, Regional and Comparative Perspectives (Institute of Historical Research, 2015) and journal articles  in  Medical History,  English Historical Review and  Irish Historical Studies. His research in this volume emanates from the AHRC ‘Poverty and Public Health in Belfast and the North of Ireland’ project based at Queen’s University Belfast. Anne Mac Lellan is a biomedical scientist and historian. She is a fellow of the Academy of Clinical Science and Laboratory Medicine and completed a Ph.D. in history at the Centre for the History of Medicine in Ireland, University College Dublin. In 2013, she won the Royal College of Physicians of Ireland medical research award. She is the author of Dorothy Stopford Price: Rebel Doctor (Irish Academic Press, 2014) and co-editor of Growing Pains: Childhood Illness in Ireland, 1750–1950 (Irish Academic Press, 2013). She is also the co-author (with Niamh Nic Ghabhann and Fiona Byrne) of World within Walls: From Asylum to Contemporary Mental Health Services: A History of St Davnet’s, Monaghan (Health Service Executive, 2015). Patricia Marsh completed her Ph.D. at the Centre for the History of Medicine in Ireland, Ulster University, on the topic of influenza in twentiethcentury Ireland. She has presented widely on the topic and is currently finalising her thesis for publication. Ian Miller is a Wellcome Trust Research Fellow in Medical Humanities at the Centre for the History of Medicine in Ireland, Ulster University. He is the author of A Modern History of the Stomach: Gastric Illness, Medicine and British Society, 1800–1950 (Pickering & Chatto, 2011); Reforming Food in Post-Famine Ireland: Medicine, Science and Improvement, 1845–1922 (Manchester University Press, 2014); Water: A Global History (Reaktion Books, 2015); and ForceFeeding, 1909–74: Hunger Strikes, Prisons and Medical Ethics (Palgrave Macmillan, 2016). He has held visiting fellowships and academic positions at Max Planck Centre for the History of Emotions (Berlin), INSERM (Paris), Institute for General Practice and Community Medicine (Oslo), University of Manchester and University College Dublin. Ian regularly acts as a media consultant to television and film companies including the BBC and has written for newspapers including the Guardian and Times Literary Supplement. Steven O’Connor is a European Union Marie Skłodowska–Curie fellow at the Centre of History, Sciences PO, Paris. He was awarded his Ph.D. in history from University College Dublin in 2012. His research in this volume was

List of contributors

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supported by the Irish Research Council. His first monograph, Irish Officers in the British Forces, 1922–45, was published by Palgrave Macmillan in 2014. Jennifer Redmond is a lecturer in twentieth-century Irish history at Maynooth University, Ireland. She is also the President (2014–17) of the  Women’s History Association of Ireland. She holds a BA (hons.) from University College Dublin and an M.Phil. and Ph.D. from the School of Histories and Humanities. The research in this volume was supported by the Irish Research Council and the Royal Irish Academy. Her latest collection,  Sexual Politics in Modern Ireland  (co-edited), was published by Irish Academic Press in March 2015. Fionnuala Walsh is a doctoral candidate and Irish Research Council Government of Ireland postgraduate scholar at Trinity College Dublin. Her work explores the impact of the Great War on women in Ireland, focusing on the years 1914 to 1919. Her previous work includes a local study of Celbridge town during the First World War, published in the Journal of the Kildare Historical and Archaeological Society (2013). Fionnuala has also written short pieces on topics including household management in the First World War. Her research in this volume was supported by the Irish Research Council.

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Acknowledgements

This volume owes its origin to a workshop held in University College Dublin which was generously supported by the Centre for the History of Medicine in Ireland. We would like to thank the staff members at the Centre for their support and enthusiasm, in particular Catherine Cox, Greta Jones, Leanne McCormick and Andrew Sneddon. We owe a particular debt of gratitude to the contributors to this volume for their enthusiasm, patience and insightful work. Manchester University Press has offered efficient guidance and we would like to thank both the team and the anonymous reviewers for their detailed and astute feedback on each of the chapters. David Durnin and Ian Miller

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Introduction David Durnin and Ian Miller

Modern wars characteristically disrupt and affect individual life. Civilians are called upon to fight; technologies of war (such as planes and submarines) bring conflict to the domestic front; sophisticated, often lethal, weapons maim and kill.1 Governments reorganise medical personnel at both sites of conflict and home. In turn, doctors find themselves treating an array of conditions that they would not normally encounter in peacetime. Moreover, war has been known to encourage the spread of disease and illness, as exemplified by the global spread of influenza towards the end of the First World War.2 Medicine itself has played an important role in treating, managing and understanding the physical and psychological conditions associated with modern war, including shell shock and dismembering conditions requiring amputation.3 Indeed, patient experiences of war have rapidly adjusted as the so-called modern ‘war machine’ became increasingly rationalised and effective in its power to maim and kill. The nature of smaller civil conflicts has also been affected by the modern nature of combat, a development with equally important implications for medicine and health. Recent studies of the Northern Irish Troubles have revealed a considerable reorganisation of medical resources, medical ethical problems with managing hunger strikers and the roles of doctors who work in conflict zones becoming severely compromised.4 Issues relating to medicine and health are, beyond doubt, central to modern conflict. In recent decades, Irish medical history has blossomed by integrating prominent themes in the international historiography including nutrition, mental health provision, gender and medicine, sexuality, childhood illness and the management of once-fatal diseases including tuberculosis.5 Yet medical historians of Ireland have paid scant attention to the relationship between health, medicine and conflict, even despite the prominence of war-related studies in the medical historiography of other western countries. Internationally, the

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Medicine, health and Irish experiences of conflict

medical, psychological and health aspects of war have been covered in sophisticated, nuanced studies.6 The absence of similar analyses within Irish historiography is all the more surprisingly, given the prominence of conflict in the country throughout the twentieth century, including participation in the First World War, a war of independence, a civil war and the Northern Irish Troubles. While the political aspects of these conflicts have been discussed in depth, considerable scope exists for historians to expand the analytical boundaries of their research to encompass deeply personal issues such as health, medicine, emotions, psychological well-being, ethics, medical employment and wartime medical migration. Broadening the scope of historical research into Irish conflict seems all the more important given the decade of commemorations, which is occurring at the time of writing.7 This volume redresses this imbalance with the hope of encouraging future research into relatively unexplored areas of twentieth-century Irish conflict. It is arranged thematically to cover three key areas: (1) health and disease on the domestic front; (2) health and political unrest; and (3) institutions and medical personnel. Part I:  Health and disease on the domestic front The conflicts that took place between 1914 and 1945 had a significant impact on Irish domestic life. Modern wars were distinct in the sense that they not only affected soldiers on the battlefield, but also took their toll on those who remained at home. In First World War Ireland, concern mounted about the health and vitality of the Irish population; particularly in relation to more vulnerable sections such as the young. The natural flow of food supplies in and out of Ireland was severely disrupted, causing apprehension about national nutritional health. Increasingly sophisticated technologies such as battleships and U-boats made both Britain and Ireland vulnerable to having food supplies cut off; a scenario that, at worst, raised fears of a second Famine.8 In light of such circumstances, attention became directed to the health and well-being of those living in rural and urban poverty. For many observers, the sprawling slums of cities such as Dublin seemed to breed disease and mental disorder.9 The anxieties that arose in Ireland were not necessarily unique to the war. Indeed, issues such as poor-quality diet, the health of the poor and alarmingly high tuberculosis levels and infant mortality rates had caused concern for some decades.10 Yet the new physical hardships created by war drew attention to these preexisting health problems, prompting considerable debate and discussion. Historians have long debated the impact of the First World War on medicine and health. Some have argued that the apparent likelihood of war in the opening decade of the century encouraged health reforms and strategies designed to boost the vitality of nations, thereby improving the chances of military victory.11 Jay Winter posits that in Britain, mortality rates declined, state bodies and voluntary groups reformed aspects of medical care in light of

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Introduction

a growing anxiety about health, and standards of living improved in many countries.12 However, Roger Cooter has rejected the argument that the First World War benefited medicine and encouraged medical innovations, as ‘overtly positivist, implicitly militarist and profoundly simplistic’.13 In the opening chapter to this volume, Fionnuala Walsh adds to this debate by demonstrating that the First World War heightened anxieties about the large number of Irish deaths, both on the battlefield and at home. Focusing on maternal and infant health, she investigates the development of wartime initiatives intended to improve health and raise the stock of the Irish nation. Not all were successful, but some measures undoubtedly benefited mothers and infants. Importantly, Walsh examines the political discourses that surrounded First World War health initiatives. During the First World War, discussion of Irish health was played out in the context of differing republican and Unionist perspectives.14 Walsh firmly demonstrates that discussion of maternal and infant health was deeply inflected by the divergent political perspectives which invariably blamed the failings of British governance for poor Irish health or sought reform within the pre-existing political system. In the 1910s, Irish health was a highly politicised matter; the political discourses that surrounded public discussion differed profoundly compared to other countries. The First World War also saw a virulent influenza pandemic which struck Ireland between 1918 and 1919 and which, internationally, killed more people than the war itself. The Great Flu permeated all aspects of Irish life, disrupting politics, schools and communities. In Ireland, the flu is thought to have claimed over 20,000 lives and infected up to 800,000 more people.15 In her contribution to this volume, Patricia Marsh examines the impact of influenza on Irish society, with an emphasis on the province of Ulster (see Chapter 2). She demonstrates that the complex politics of that region – influenced by Unionist politics and a strong desire to support the war effort – shaped media coverage of influenza and the organisation of schemes implemented to tackle the disease. The subject of influenza became entangled with far broader political debates on the introduction of conscription and the need to maintain public morale in a period when Irish independence appeared increasingly likely. Although Ireland remained neutral during the Second World War, the country did not escape the privations of warfare. Food became scarce, medical supplies began to run out and public health suffered. Diseases such as typhus re-emerged; certain sections of the population began to fear a second Famine; the poor experienced particular adversity.16 Bryce Evans’s chapter provides a compelling overview of the physical and nutritional hardship endured by the Irish (particularly the poor) between 1939 and 1945. As Evans suggests, Ireland effectively lived through the war despite its neutrality, being subject to a stringent war economy with detrimental health ramifications. Food, in particular, became a highly contentious issue. Indeed, as Evans demonstrates, food had occupied an important place in the Irish national psyche since the Famine and

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Medicine, health and Irish experiences of conflict

proved central to sociocultural discourses on Irish health and well-being during the Emergency. Expanding upon key themes opened up in Evans’s chapter, Anne Mac Lellan in Chapter 4 demonstrates that Ireland was the only neutral county in which tuberculosis levels rose during the Second World War. Historically, tuberculosis had beset Ireland. In the early twentieth century, tuberculosis death rates continued to rise in Ireland at a time when they were rapidly declining in most other western countries.17 As Mac Lellan suggests, this presented an increased disease burden at a time of sociopolitical and economic stress. Yet renewed anxiety about tuberculosis encouraged improvements in services and health policies, most notably the widespread extension of the use of BCG vaccines. Combined, the chapters in Part I demonstrate that international warfare had a profound impact on the spectrums of Irish life during both the First and Second World Wars, despite Irish neutrality in the latter conflict. The chapters illuminate the complexities that became attached to issues such as food, disease, childhood and public health. War often disrupted day-to-day activities such as purchasing food. Yet, in some instances, the crisis produced by international warfare encouraged policy change and improved provision of health services. Irish experiences of health during these two conflicts were varied and multifaceted. The Irish population undoubtedly suffered hardship, but also gained access to some improvements in healthcare. Importantly, the chapters also determine the uniqueness of Irish experiences of health and medicine on the domestic front. In the First World War, health became highly politicised; entangled in far broader debates on whether or not Ireland should gain independence. During the Emergency, Ireland had the unique experience of wartime hardships despite being neutral. Part II:  Health and political unrest In addition to being involved in the First World War, Ireland witnessed what is often referred to as the ‘revolutionary period’; a ten-year period (c.1913–23) of sociopolitical tumult that led to the formal granting of independence.18 Class divisions between employers and employees came to the fore during the dramatic Dublin Lockout of 1913; a protracted period of labour tension that raised international awareness of adverse living conditions in Dublin’s extensive slum network.19 Meanwhile, the suffragette movement was making considerable inroads in Ireland. Its members openly questioned the gendered structure of Irish society by upholding the right of Irish women to vote and hold public office.20 From around the start of the twentieth century, the Irish nationalist movement became increasingly vocal, influential and militaristic.21 Two paramilitary forces came into existence just prior to the outbreak of war: the Ulster Volunteers – formed in opposition to Home Rule – and the Irish Volunteers, a group founded with the agenda of securing Home Rule.22

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Introduction

The First World War added considerable complexity to an already intricate sociopolitical culture. During the war years, the constitutional path to Irish independence promoted since the late nineteenth century by the Irish Parliamentary Party was severely undermined by the electoral gains of the assertively republican Sinn Féin party. In 1918, Sinn Féin secured seventy-three seats out of a total of 105 available for Ireland in the Parliament of the United Kingdom, although Unionists retained a majority in the northern province of Ulster.23 War also encouraged militarism.24 For instance, the Irish Republican Brotherhood (IRB) adopted an aggressive approach to securing Irish national freedom and staged the Easter Rising in 1916.25 Violence and conflict was now just as much a part of life on the Irish home front as it was on the battlefield.26 In 1918, Sinn Féin members refused to take their seats in the House of Commons and pledged to set up an autonomous Irish parliament. The First Dáil government (legally unrecognised by the British government) met for the first time in January 1919 at Mansion House, Dublin.27 The Irish War of Independence followed; a period of national violence in which the Irish Republican Army (IRA), the army of the self-proclaimed Irish Republic, fought a protracted guerrilla war against the British government and its forces in Ireland.28 The autonomous Irish Free State was established in 1922 although conflict ensued between two opposing republican groups over the contested terms of the Anglo-Irish Treaty which left six counties in the north of Ireland within the United Kingdom. Contestation over this matter resulted in the Irish Civil War (1922–23), a violent conflict between pro- and anti-Treaty factions of the republican movement.29 The medical aspects of these conflicts have barely been examined.30 Yet, in this period, men, women and children were shot; politicised prisoners were force-fed; participants suffered emotional distress; doctors treated battle wounds. A recent monograph by Ian Miller on the history of force-feeding, based upon earlier published work on English suffragette hunger striking, has brought to life the ethical complexities of caring for, and managing, hunger strikers in historical contexts including the War of Independence and Civil War.31 Conflict is always about bodies and minds, even despite an emphasis on the political and military in pre-existing accounts of this period in Ireland. This is aptly demonstrated in Barry Kennerk’s contribution to this volume which, uniquely, looks at the children who were shot and injured in the Easter Rising (see Chapter 5). Situating his analysis in the broader context of concern over Irish urban childhood, Kennerk investigates the medical resources and surgical techniques available in 1916, providing a vivid account of injury, suffering and, in some cases, childhood death. National conflict brought Irish doctors and surgeons firmly into the battlefields of rebellion; medical resources needed to be swiftly reorganised to support the medical needs of the injured. Focusing on medical provision for those wounded in Ireland’s domestic conflicts, David Durnin in Chapter 6

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explores the role of Ireland’s British Army doctors in treating nationalists throughout the revolutionary period. Irish doctors enlisted into the British Army medical services from at least the eighteenth century. This continued throughout the First World War and its immediate aftermath. Durnin details the significant role that these men played in treating the wounded nationalists in the 1916 Rising, as well as their experiences of the War of Independence and Civil War. During these conflicts, separatist nationalist groups, such as the IRA, specifically sought the assistance of Irish doctors because of the experience they had gained in treating wounded soldiers in the First World War. As such, ex-British Army doctors returned to Ireland and were able to negotiate their professional positions through the context of Irish conflict. In Chapter 7, Fiachra Byrne examines the hallucinations suffered by an IRA member during the War of Independence. He demonstrates that mental disorder could be experienced and interpreted in light of the social and sectarian conflict that afflicted the north of Ireland in the early 1920s. Michael Nolan was the medical superintendent of Down County Mental Hospital where he encountered this anonymised patient. The hallucinations which he recorded provide a record of how psychiatry, warfare, religion and society intersected; psychological distress was recorded using politico-military metaphors, once again demonstrating that the various conflicts in revolutionary-period Ireland had important implications for patients and medical staff. Combined, the chapters in Part II highlight the unique medical ramifications of conflict for Irish civilians, participants, doctors and psychiatrists, offering a lens into the physical, emotional and ethical ramifications of Irish conflict. Part III:  Institutions and medical personnel Medical personnel played a considerable role in both world wars. Doctors, general practitioners, surgeons and nurses, among others, provided healthcare to sick and wounded soldiers on the battlefields and in the numerous hospitals located in Britain and Ireland. The role of medics in the wars has been the subject of several recent studies. In particular, there has been an upsurge in historical interest in medical provision during the First World War. Ian Whitehead’s research has focused specifically on the enlistment of medical officers into the Royal Army Medical Corps, a specialist corps responsible for providing medical care to all British Army personnel, to serve in the war. Whitehead demonstrates that large numbers of doctors throughout Britain enlisted into the corps from 1914 to 1918.32 Leo Van Bergen has explored the wounds and illnesses suffered by combatants on both sides of the conflict and the role of doctors in treating these men, arguing that medical personnel were one of the largest groups of academically trained professionals participating directly in the war effort.33 In 2010, Mark Harrison, in his groundbreaking study The Medical War: British Military Medicine in the First World War, has

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Introduction

explored the role of the British Army medical services in the First World and detailed the development of the casualty clearing process in several theatres of war, including the Western Front, Mesopotamia, Gallipoli and East Africa. Harrison argues that the Royal Army Medical Corps’ casualty-clearing process reduced the wastage of military personnel.34 These studies have significantly enhanced our understanding of the British Army’s medical arrangements during the First World War. Recently, significant work has been carried out to examine Irish medical involvement in the First World War.35 Yet there is still much historical analysis required. Several chapters in this volume explore aspects of Irish medical provision during the war that has up until now been neglected. In Chapter 9 Seán Graffin examines the role of Belfast nurses in the First World War. It has been estimated that approximately 4,500 Irish nurses participated in the conflict.36 Through an analysis of a cohort of these, Graffin offers an insight into Irish nurses’ motivations for enlisting and their wartime experiences. The outbreak of the war necessitated a considerable administrative effort from those responsible for providing healthcare in Belfast. Throughout the conflict, hospital governors and the medical profession strived to ensure that the enlistment of medics into the British Army did not disrupt healthcare in Ireland. Graffin interrogates this complex undertaking in Belfast and analyses the significant reorganisation of the nursing profession in the city to cater for the unprecedented number of casualties transported into the hospitals in the region. From 1914 to the 1920s, soldiers returned to Ireland for treatment in civilian hospitals, asylums and specially established war wards. Focusing on this, Ronan Foley in Chapter 8 analyses the complex geographical networks that led the sick and wounded soldier from the battlefields to treatment in Irish domestic hospitals. Importantly, Foley contextualises these networks by mapping the locations and routes of wartime medical care. A considerable expansion of military and voluntary medical infrastructure occurred in Ireland during the war to treat returning sick and wounded soldiers. Foley explores the establishment of specialist wartime hospitals in Ireland and in doing so, demonstrates the considerable efforts of voluntary bodies in providing healthcare facilities for the military. Building upon this key theme, Clara Cullen in Chapter 10 explores the work of the Sphagnum Moss Depot, established in the Royal College of Surgeons in Ireland in 1914. In doing so, Cullen demonstrates the notable expansion of voluntary work in Ireland from August 1914 to meet the demands of war. While not subject to the same recent upsurge in historical interest as the First World War, several international studies have examined various facets of health and medical provision during the Second World War. For instance, Mark Harrison has authored a comprehensive account of British military medicine during the conflict, examining medical work in the main theatres of war.37 Ben Shephard has examined psychiatry during the conflict, while Lesley

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Medicine, health and Irish experiences of conflict

A. Hall has explored the attempts to control sexually transmitted diseases in the British Army.38 There has been minimal work completed on Irish medical involvement in the conflict. Despite being neutral, the Irish political and social situation during this conflict was inherently complex. Partition had separated northern counties of Ireland from the south, while the traditional Irish propensity for emigrating to countries including Britain (encouraged by deep levels of poverty and hardship) persisted even after independence. Seán Lucey examines the Emergency Hospital Services in Northern Ireland during the Second World War (see Chapter 11). These services, which included casualty services, blood transfusion and a pathological service, were vital to paving the way for the National Health Service. Lucey argues that following the establishment of the Emergency Hospital Services, large numbers were entitled to free health services for the first time, which widened expectations of the role of the state. In addition, Lucey determines that the medical profession played a significant role in the establishment and shaping of these services, demonstrating their highly influential role in healthcare politics in Northern Ireland. The final chapters in Part III demonstrate that the arrival of independence did not signal the end of the participation of Irish medical personnel in the British Army. Instead, and perhaps surprisingly, Irish doctors continued to be over-represented in the British forces during the interwar years and into the Second World War. In Chapter 12 Steven O’Connor examines the continuation of the enlistment of Irish doctors into the Royal Army Medical Corps from 1922 to 1945. O’Connor suggests that several complex and multifaceted factors, including the state of Ireland’s medical profession, motivated this continued involvement. Importantly, O’Connor explores the social backgrounds of a sample of those who enlisted from 1922 to 1945 to give further insight into the motivations for enlistment. In doing so, O’Connor demonstrates that, despite the fraught relations between Britain and Ireland during the interwar years, ultimately, the British and Irish medical professions retained their professional links to the benefit of Irish doctors. Expanding on this theme, Jennifer Redmond (Chapter 13) examines the experiences of Irish immigrants in the wartime British sector. Not all of Ireland’s medical participants in the Second World War joined directly from Ireland. Instead, there were many who had already migrated to Britain and held various hospital posts and general practices. These men and women assisted the British war effort. Through a thorough investigation of travel permit application files, Redmond argues that Irish doctors and nurses in the British medical profession occupied the full spectrum of roles and contributed much during the Second World War. The chapters in Part III make clear that nurses, doctors, volunteers and military medical staff from Ireland were central to the First and Second World Wars. Ireland was very much a part of modern warfare, even in conflicts in which the (southern part of the) country did not partake.

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Introduction

Overall, this volume brings to life the multifaceted, and often highly unique, experiences of the Irish as their country transitioned through a traumatic period of partaking in international conflict, staging a war against the British state, fighting against one another during a civil war, gaining semiindependence, and navigating the problems associated with staying neutral in a further international war. It recaptures the experiences of medical staff, armed rebels, emigrants, patients, mothers and volunteers. Perhaps most importantly, it makes a case for the relative uniqueness of Irish experiences of war and conflict. Notes   1  D. Pick, War Machine: The Rationalisation of Slaughter in the Modern Age (New Haven, CT: Yale University Press, 1996).   2  See R. Cooter, ‘Of war and epidemics: unnatural couplings, problematic conceptions’, Social History of Medicine, 16:2 (August 2003), 238–302. Literature on influenza is vast (and is thoroughly covered in Patricia Marsh’s contribution to this volume – see Chapter 2).   3  J. Bourke, Dismembering the Male: Men’s Bodies, Britain and the Great War (London: Reaktion Books, 1999); B. Shephard, A War of Nerves: Soldiers and Psychiatrists, 1914–1994 (Cambridge, MA: Harvard University Press, 2001).   4  F. Manzoor, J. McKenna and G. Jones, Candles in the Dark: Medical Ethical Issues in Northern Ireland during the Troubles (London: Nuffield Trust, 2009).   5  See, among various others, G. Jones and E. Malcolm (eds), Medicine, Disease and the State in Ireland, 1650–1940 (Cork: Cork University Press, 1999); G. Jones, ‘Captain of All These Men of Death’: The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (Amsterdam: Rodopi, 2001); L. McCormick, Regulating Sexuality: Women in Twentieth-Century Northern Ireland (Manchester: Manchester University Press, 2009); C. Cox and M. Luddy (eds), Cultures of Care in Irish Medical History, 1750–1970 (Basingstoke: Palgrave Macmillan, 2010); M. Preston and M. Ó Hógartaigh (eds), Gender and Medicine in Ireland, 1700–1950 (New York: Syracuse University Press, 2012); C. Cox, Negotiating Insanity in the Southeast of Ireland, 1820– 1900 (Manchester: Manchester University Press, 2012); A. Mac Lellan and A. Mauger (eds), Growing Pains: Childhood Illness in Irish History, 1750–1950 (Dublin: Irish Academic Press, 2013); I. Miller, Reforming Food in Post-Famine Ireland: Medicine, Science and Improvement, 1845–1922 (Manchester: Manchester University Press, 2014); A. Mac Lellan, Dorothy Stopford Price: Rebel Doctor (Dublin: Irish Academic Press, 2014).   6  See, among others, D. Dwork, War Is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England, 1898–1918 (London: Tavistock, 1987); R. Cooter, M. Harrison and S. Sturdy (eds), War, Medicine and Modernity (Stroud: Sutton, 1998); M. Harrison, Medicine and Victory: British Military Medicine in the Second World War (Oxford: Oxford University Press, 2009); M. Harrison, The Medical War: British Military Medicine in the First World War (Oxford: Oxford University Press, 2010); A. Carden-Coyne, The Politics of Wounds: Military Patients and Medical Power in the First World War (Oxford: Oxford University Press, 2014).   7  J. Horne and E. Madigan, Towards Commemoration: Ireland in War and Revolution, 1912–1923 (Dublin: Royal Irish Academy, 2013).

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10

Medicine, health and Irish experiences of conflict   8  Miller, Reforming Food in Post-Famine Ireland, pp. 173–96.   9  J. Prunty, Dublin Slums, 1800–1925: A Study in Urban Geography (Dublin: Irish Academic Press, 1998). 10  Jones, ‘Captain of All These Men of Death’. 11  See, for instance, Dwork, War Is Good for Babies. 12  See J. M. Winter, The Great War and the British People (Basingstoke: Palgrave Macmillan, 1985), pp. 103–248. 13  R. Cooter, Surgery and Society in Peace and War: Orthopaedics and the Organization of Modern Medicine, 1880–1948 (London: MacMillan, 1993), p. 105. 14  For discussion of the politicisation of Maud Gonne’s school meals campaign in the 1910s, see Miller, Reforming Food in Post-Famine Ireland, pp. 155–72. 15  C. Foley, The Last Irish Plague: The Great Flu Epidemic in Ireland, 1918–19 (Dublin: Irish Academic Press, 2011). 16  C. Wills, That Neutral Island: A Cultural History of Ireland during the Second World War (London: Faber and Faber, 2007), pp. 239–45, pp. 257–62; B. Evans, Ireland during the Second World War: Farewell to Plato’s Cave (Manchester: Manchester University Press, 2014). 17  Jones, ‘Captain of All These Men of Death’. 18  For recent treatments, see D. Ferriter, A Nation and Not a Rabble: The Irish Revolution, 1913–23 (London: Profile Books, 2015); M. Walsh, Bitter Freedom: Ireland in a Revolutionary World 1918–1922 (London: Faber and Faber, 2015). 19  P. Yeates, Lockout: Dublin 1913 (Dublin: Gill & Macmillan, 2001); F. Devine (ed.), A Capital in Conflict: Dublin City and the 1913 Lockout (Dublin: Dublin Corporation Public Libraries, 2013). 20  See R. C. Owens, Smashing Times: A History of the Irish Women’s Suffragette Movement, 1889–1922 (Dublin: Attic Press, 1984); L. Ryan and M. Ward (eds), Irish Women and the Vote: Becoming Citizens (Dublin: Irish Academic Press, 2007). 21  For an overview of the various forms of nationalism, see T. Hennessey, Dividing Ireland: World War One and Partition (London: Routledge, 1998), pp. xi–xxi. For Unionism, see P. Bew, Ideology and the Irish Question: Ulster Unionism and Irish Nationalism, 1912–16 (Oxford: Clarendon Press, 1994). 22  For Unionism, see T. Bowman, Carson’s Army: The Ulster Volunteer Force, 1910–22 (Manchester: Manchester University Press, 2012). A standard text on the Irish Volunteers is F. X. Martin, The Irish Volunteers 1913–15: Recollections and Documents (Dublin: James Duffey, 1963). 23  M. Laffan, The Resurrection of Ireland: The Sinn Féin Party, 1916–1923 (Cambridge: Cambridge University Press, 1999). 24  D. Ferriter, The Transformation of Ireland, 1900–2000 (London: Profile Books, 2004), p. 111. 25  O. McGee, The IRB: The Irish Republican Brotherhood from the Land League to Sinn Féin (Dublin: Four Courts Press, 2007). 26  For discussion of violence in revolutionary Ireland, see T. Fanning, The Fatal Path: British Government and Irish Revolution, 1910–1922 (London: Faber and Faber, 2013). 27  Laffan, Resurrection of Ireland, pp. 266–303. 28  For the Irish War of Independence, see, among others, M. Hopkinson, The Irish War of Independence (Dublin: Gill & Macmillan, 2002). For discussion of IRA activities in this period, see P. Hart, The IRA and Its Enemies: Violence and Community in Cork, 1916–1923 (Oxford: Clarendon Press, 1998) and The IRA at War, 1916– 1923 (Oxford: Oxford University Press, 2003). 29  M. Hopkinson, Green against Green: A History of the Irish Civil War (Dublin: Gill & Macmillan, 1988).

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Introduction 30  One exception is I. Miller, ‘Pain, memory and trauma in the Irish revolutionary period’, in F. Dillane, E. Pine and N. McAreavy (eds), Memory and Trauma: The Body in Irish Culture (Basingstoke: Palgrave Macmillan, 2016). 31  Ian Miller, A History of Force Feeding, 1909–74: Hunger Strikes, Prisons and Medical Ethics (Basingstoke: Palgrave Macmillan, 2016). For earlier publications on medical ethics, prison medicine and hunger striking, see Ian Miller, ‘Necessary torture? Digestive physiology, vivisection, the suffragette movement and responses to new forms of clinical practice in Britain, c.1870–1920’, Journal of the History of Medicine and Allied Sciences, 64:3 (October 2009), 333–72; Ian Miller, ‘ “A prostitution of the profession?” Forcible feeding, prison doctors, suffrage and medical ethics’, Social History of Medicine, 26:2 (April 2013), 225–45. 32  I. Whitehead, Doctors in the Great War (Barnsley: Leo Cooper, 1999). 33  L. Van Bergen, Before My Helpless Sight: Suffering, Dying and Military Medicine on the Western Front, 1914–1918 (Surrey: Ashgate, 2009); L. Van Bergen, ‘Military medicine’ in J. M. Winter, The Cambridge History of the First World War: Civil Society (3 vols, Cambridge: Cambridge University Press, 2014), vol. III, pp. 287–309. 34  Harrison, Medical War. 35  D. Durnin, ‘Medical provision and the Irish experience of the First World War, 1912–25’ (Ph.D. dissertation, University College Dublin, 2015); P. J. Casey, K. T. Cullen and J. P. Duignan, Irish Doctors in the First World War (Dublin: Merrion Press, 2015); Y. McEwen, It’s a Long Way to Tipperary: British and Irish Nurses in the Great War (Dunfermline: Cualann Press, 2006). 36  C. Clear, ‘Fewer ladies, more women’, in J. Horne, Our War: Ireland and the Great War (Dublin: Royal Irish Academy, 2008). 37  Harrison, Medicine and Victory. 38  Shephard, War of Nerves; L. A. Hall, ‘ “War always brings it on”: war, STDs, the military and the civilian population in Britain, 1850–1950’, in R. Cooter, M. Harrison and S. Sturdy (eds), Medicine and Modern Warfare (Amsterdam, Rodopi Press, 1999).

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PART I:

Health and disease on the domestic front

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1

‘Every human life is a national importance’: the impact of the First World War on attitudes to maternal and infant health Fionnuala Walsh

‘We must avoid a continued slaughter of the infants as every human life is of national importance.’ So stated prominent barrister Samuel Shannon Millin in 1915, referring to the need to address the appallingly high infant mortality rate in Ireland, at a time when many Irish lives were being lost on the battlefield.1 In early twentieth-century Ireland, infant mortality (the death of a child aged less than 12 months) was a serious problem. The issue received heightened attention during the First World War in both Great Britain and Ireland. The number of recruits deemed physically unfit for military service led to a greater recognition of the devastating impact of poverty on health, while the unprecedented loss of life on the battlefields simultaneously raised concern about the vitality of the nation.2 In Ireland, infant and maternal health captured the attention of various politically disparate groups. This chapter examines this wartime apprehension and investigates the impact of the war on infant and maternal mortality as it arose in Ireland. It builds upon previous work by scholars such as Janet Dunwoody, Lindsey Earner-Byrne and Ian Miller to offer a comprehensive examination of the wartime infant welfare movement, and a quantitative analysis of wartime trends in infant and maternal mortality in Ireland.3 By considering the wider United Kingdom context, the particularity of the Irish situation will be established. Overall, this chapter argues that the turbulent political situation in Ireland strongly affected attempts to combat infant mortality, leading to significant differences in public attitudes towards the welfare movements in Great Britain and Ireland.

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The pre-war infant welfare movement Ireland had the lowest infant mortality rate in Europe during the last quarter of the nineteenth century. Although this rose during the 1890s, it remained significantly below the levels witnessed elsewhere in the United Kingdom.4 However, the difference between urban and rural Ireland was very evident. For instance, Dublin had a particularly high infant mortality rate.5 Social class was a key determinant of infant mortality rates. The babies of labourers were seventeen times more likely to die in their first year than the children of professional households.6 High unemployment levels, poor sanitation and overcrowded housing in Ireland’s urban areas combined to create potentially lethal conditions for infants. Increasing attention was paid to the problem in the years immediately preceding the First World War. Various voluntary organisations attempted to address the issue, most notably the Women’s National Health Association (WNHA). The WNHA was established in 1907 under the guidance of the Countess of Aberdeen Ishbel Gordon, wife of the Lord Lieutenant of Ireland. Although primarily concerned with eradicating tuberculosis, its initial objectives included promoting the rearing of a ‘healthy and vigorous race’.7 By 1911 the WNHA had 155 branches and almost 18,000 members across Ireland.8 Their work was heavily influenced by neo-hygienist doctrines that highlighted maternal ignorance as a leading cause of high infant mortality rates. Accordingly, their activities were primarily educational in focus.9 From 1908, they operated mother-and-baby clubs in Belfast and Dublin. At the clubs, babies were weighed and doctors were available to provide medical advice. Home visits by nurses to investigate feeding and hygiene regimes also took place.10 Similar initiatives were taking place in Great Britain at the same time. Carol Dyhouse’s work on infant mortality in pre-war London reveals the extent of the problem in Britain’s cities, and the various attempts made to combat the issue. She claims that between 1900 and 1914 the subject had become ‘defined by contemporaries as one of the major social problems of the time’.11 A wide range of organisations and initiatives developed in Britain to promote infant welfare. These included baby shows, which offered prizes for breast-fed babies, as well as nursing mothers’ restaurants, milk depots and ‘schools for mothers’. This ‘rapid mushrooming’ of infant welfare centres resulted from both voluntary and municipal efforts.12 The increased interest in the area was affected by societal concern with racial degeneration following the high rejection rates at recruiting stations during the Boer War (1889– 1902).13 Although Miller has noted the influence of long-standing non-military social issues such as diet and health on concerns about national decline, Francesca Moore also points to the crisis of the Boer War as having encouraged infant mortality to be increasingly seen as a target for state intervention.14

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First World War attitudes to maternal/infant health

In both Britain and Ireland, emphasis was placed on educating the mothers to take better care of their children rather than improving the adverse conditions in which many working-class people lived. Influential contemporary commentators dismissed the impact of poverty and the poor housing and sanitation conditions in overcrowded urban areas as of little relevance to infant mortality rates. Arthur Newsholme, chief medical officer of the Local Government Board for England and Wales from 1908 to 1919, claimed that any attempt to reduce infant mortality by addressing poverty would be ‘unscientific’.15 The pre-war infant welfare movements were very similar in Ireland and Great Britain, sharing a common focus on maternal education and promoting domestic hygiene. However, the Boer War had less impact in Ireland where the discussion continued to concentrate on problems arising from postFamine dietary customs.16 Across the United Kingdom scientific advancements in the understanding of the role of bacteria in causing infection led to a new optimism that infant mortality rates could be radically reduced with appropriate education.17 Another war provided further incentive for attempts to improve infant survival rates. Infant welfare and the First World War The outbreak of the First World War brought renewed attention to the topic in both Britain and Ireland. The high numbers of men rejected as physically unfit for military service (41 per cent of all recruits examined in Great Britain during 1917 and 1918) caused great concern to the government.18 However, it was the unprecedented losses suffered by the British Army that caused particular anxiety about the strength of the national race and the military might of the Empire.19 This apprehension, combined with a declining wartime birth rate, resulted in increased investment in infant welfare. The realisation of the impact of maternal health on infant survival chances also brought greater attention to the problem of maternal mortality.20 This imperialist anxiety was evident in Ireland as well as in Great Britain. Edward Coey Bigger, Crown representative for Ireland on the General Medical Council, explained this wartime concern in the introduction to his 1917 report on maternal and infant welfare in Ireland: For this paradox has come about that this sacrifice, with its almost wanton disregard of human life, has made life more highly valued and has turned the minds of many to how it may be saved … Ireland needs men and yet of every hundred children born, nine die before they reach the age of twelve months.21

His report was part of a series commissioned by the Carnegie United Kingdom Trust to research the physical welfare of mothers and children in England, Wales, Scotland and Ireland. The report met with widespread

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Health and disease on the domestic front

approval in Ireland. The Local Government Board for Ireland cited its usefulness for their organisation of maternal and child welfare schemes and for its ‘undoubted effect in stimulating interest in this important area’.22 The agricultural periodical, Irish Homestead, similarly considered it a document of ‘the utmost value’ and one that should be read by all those interested in reform in Ireland.23 Such anxiety about the future generations was also evident in two papers presented to the Statistical and Social Inquiry Society of Ireland during the war. Millin asserted in 1915 that the importance of child life as a national asset has ‘never in the history of the British Empire been brought into greater prominence than at the present moment when thousands of our fellow countrymen are perishing on the battlefield in the prime of manhood’.24 Similar sentiments were expressed by William Lawson, barrister and president of the Social and Statistical Inquiry Society of Ireland, in his 1917 paper on infant mortality and the Notification of Births Act.25 Frequent comparisons were made between the infant mortality rate and the survival chances of soldiers in the trenches, reflecting a heightened sensitivity towards unnecessary deaths and the loss of Irish lives. Bigger’s claim that a baby born in Dublin in 1915 had less chance of surviving the year than his father fighting in France was frequently repeated.26 During the National Baby Week campaign of 1917 the Irish Times used similarly emotive language, with phrases such as ‘the torrent of death in babyland’ and claiming that ‘Ireland’s babyhood is being slaughtered in battalions owing to Ireland’s neglect’.27 The National Baby Week campaign began in England in 1917 to help to reduce the number of infant deaths among the working class. In Ireland the movement was led by the WNHA and the Infant Aid Society but received support from many prominent figures in Dublin such as the Lord Mayor, MPs and the presidents of the Royal Colleges of Physicians of Ireland and Royal College of Surgeons in Ireland. From 1 July to 7 July 1917 an exhibition and conference on baby welfare were held in the Mansion House, Dublin. The objectives of the week were described as follows: To rouse a sense of racial responsibility in every citizen in order to secure to every child born in Ireland a birthright of mental and bodily health; to inform the public generally as to what it is now being done for children and young mothers by voluntary agencies, local authorities and the State; and to show what could be done if every citizen shouldered his or her responsibility.28

William Taylor, president of the Royal College of Surgeons in Ireland, described the baby week campaign as ‘essential to the welfare of the nation’.29 However, the Irish Homestead expressed surprise about the wartime concern with infant life, noting the apparent public apathy towards earlier campaigns to combat the issue.30 George Russell, the periodical’s editor, was correct in

First World War attitudes to maternal/infant health

asserting that infant mortality was not a new problem but he perhaps failed to appreciate the impact the wartime losses had on public attitudes to child welfare. The high visibility of death during wartime provided an important catalyst for health campaigners to draw public attention to an ongoing social problem.

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Addressing the problem The First World War accentuated anxiety about the future well-being of the Irish population, as expressed with consideration of both infant welfare and the deaths of Irish soldiers on the battlefield. But how was high infant mortality tackled during wartime? How did political tensions in Ireland affect attitudes to the subject? Infant welfare became highly politicised in Ireland during the war, taking on a unique tone, given the increasing tension between republicanism and Unionism and their relationship with imperialism. Campaigners with vastly different political opinions united around the issue of infant welfare. However, the tone of their arguments differed considerably. Unionists typically employed an imperialist rhetoric, while republicans often pointed to the inattentiveness of the British government towards Irish health to add weight to their case for national independence. These contrasting approaches to the problem of infant mortality can be seen in four contemporary Irish periodicals. The Lady of the House and the Church of Ireland Gazette, both upper-class Unionist papers, employed imperialist arguments to promote infant welfare in Ireland while also attempting to place the issue in an Irish context. They both referred to the small population of Ireland which could ill afford to lose any more of its young, with the Church of Ireland Gazette arguing that Baby Week ought to have particular appeal in Ireland: ‘We are a small race. Within living memory we have become almost halved.’31 The interest of the Church of Ireland Gazette in the issue was possibly affected by concerns with their own declining numbers. A disproportionately high number of Irish Protestants served in the armed forces in the First World War. This together with their declining marriage and birth rates may have increased the value of infant life for this sector of the Irish population.32 In common with the WNHA, the Lady of the House argued that the main cause of infant mortality was ‘lamentable ignorance’ on the part of parents as to the proper care of their babies.33 They supported the WNHA educational approach to the problem. While the paper highlighted the horrific conditions in the Dublin slums, they blamed public apathy for government inaction on the tenement issue.34 In contrast, the republican movement focused on the socio-economic factors affecting mortality, for which they were adamant the British government was to blame. The suffragist and increasingly republican paper, the Irish Citizen, laid the blame for Ireland’s high infant mortality rate at the hands of

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the British government, citing in particular the increased export of foods from Ireland to Great Britain during the war:

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By refusing self-determination to the Irish people and by confiscating the national wealth and resources of Ireland, the English government is directly responsible for the suffering and misery of the majority of the people which manifests itself in the high death rate, the horrible wastage of infant life and the consequent losses to Ireland.35

The editors of the Irish Citizen strongly opposed the war and actively emphasised its negative effects for Irish civilians to underpin their case against Irish military participation. The importance of the infant welfare movement for the Irish nation was recognised, with the paper arguing that it was ‘national work that cannot be postponed till English rule is overthrown’.36 The strongly nationalist paper, New Ireland, similarly described the issue as a ‘problem for Ourselves Alone’ (with the phrase presumably meant both literally and as a translation for the Irish republican party Sinn Féin).37 Notably, similar attempts to use child welfare concerns to attack the legitimacy of British rule in Ireland had been previously employed by republicans such as Maud Gonne during the campaign for school dinners in the years immediately preceding the First World War, not least because issues relating to ‘school-day starvation’ provided an emotive trope with which to attack British policies in Ireland.38 Although united in their desire to combat infant mortality, there were clear disagreements over the best means of tackling the problem. Tensions were also apparent between the two most prominent societies operating in the field of infant welfare during the war: the WNHA and the Infant Aid Society. The Infant Aid Society (established in 1910 as the Dublin Committee for the prevention of infantile mortality) was dismissive of the WNHA baby clubs, one of their primary initiatives. However, Dr Reginald White, chairman of the Infant Aid Society, considered them unnecessary, claiming that their work could be better performed in the maternity and children’s hospitals.39 Despite his position as Master of the National Maternity Hospital, White’s attempt to win support from Matthew Nathan, under-secretary for Ireland, met with little success.40 However, the Society received support from the strongly nationalist paper, New Ireland. In a call for immediate action to tackle the housing problem in Dublin city, the editor criticised those indulging in ‘speeches and addresses … no matter how elegant the language’ and promoted the Infant Aid Society as the ‘citizen’s own society’.41 The central role of Lady Aberdeen in the WNHA, even after her departure from Ireland in February 1915, undoubtedly influenced government support of her Association and gave it particular prominence. However, this same involvement made the Association less appealing to advanced nationalists and republicans. They criticised and mocked Lady

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First World War attitudes to maternal/infant health

Aberdeen’s public health work, considering it imbued with an imperialist agenda. For example, a republican ballad from 1910 claimed her baby clubs were attempting to anglicise Irish mothers and babies.42 Both the Irish Citizen and New Ireland were critical of the priorities of the wartime infant welfare movement in Great Britain and Ireland. The Irish Citizen described the National Baby Week campaign as a ‘fashionable’ event involving ‘silly sentimental flummery’ organised by ‘well-meaning busy bodies’.43 The paper criticised the educational focus of the campaign, complaining that it did not give due weight to the principal cause of infant mortality: poverty manifested in insufficient nutrition, poor housing conditions and inadequate sanitation facilities in urban areas.44 The editor of New Ireland similarly observed that ‘lectures on dress or cooking do not supply a remedy’ for the impact of the appalling housing conditions in Dublin on infant survival chances.45 The serious housing situation was highlighted in Bigger’s report as an important factor in mortality rates in Dublin. However, there were difficulties in dealing with the tenements during the war, due to the expense involved.46 Wartime initiatives Clearly, the issue of infant welfare became heavily politicised in wartime Ireland. Differing perspectives existed on whether mothers were responsible for the high mortality rate or the adverse social conditions in which they lived. In turn, this raised questions about the extent to which state involvement was desirable. The issue was also seized upon by some republicans to add weight to their arguments for independence. But what practical measures were implemented? Were these state-led or voluntary? Contemporaries criticised the Irish infant welfare movement for its lack of attention to the socio-economic factors affecting infant mortality. However, the wartime initiatives included attempts at social reform as well as domestic improvement. While maternal education continued to be promoted through the WNHA baby clubs and the classes on child welfare organised by the Department of Agriculture and Technical Instruction in 1917, there were also other practical measures introduced during the First World War.47 These included both legislation and more short-term initiatives such as milk depots. Supply of clean milk was a significant issue during the war, with its shortage being blamed for much of Dublin’s high infant mortality rate. Although by no means a new issue, the milk problem received increasing attention during the war.48 It was referred to repeatedly in the press in 1917. Throughout 1918 the Irish Homestead devoted much space to the issue.49 Although some governmental assistance was provided, schemes to provide clean affordable milk depended upon voluntary action.50 The WNHA and the United Irishwomen, a non-political secular organisation focused on improving the quality of

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domestic life in rural Ireland, opened milk depots in various towns and villages where milk was scarce. In 1917 twenty-eight WNHA branches had provisions for supplying clean and cheap milk to the local population while in the same year more than 22,000 gallons of milk were sold at the United Irishwomen milk depots.51 Although republican groups presented state inaction as evidence for the need for independence, some official measures were implemented. Nonetheless, these were introduced significantly later in Ireland than in England and Wales. The Notification of Births Act was extended in 1915 to all of Ireland, eight years after its implementation in England and Wales. Significantly, the Act addressed both maternal ignorance and alleviation of the hardship caused by poverty. It enabled the Local Government Board to carry out schemes for the physical welfare of mothers and young children such as provision of milk, classes in domestic hygiene for girls, formation of maternity centres to provide advice for mothers and the appointment of health visitors to advise expectant and nursing mothers in their own homes.52 A grant of £5,000 was made available from the Imperial treasury in 1916 to aid with such schemes.53 Although the grant was initially intended for the introduction of maternal and child welfare schemes in urban areas, in 1917 it was extended to rural districts.54 Their implementation was entirely voluntary however and some districts were reluctant to become involved. Celbridge District Council in Co. Kildare dismissed the scheme as ‘not workable in rural districts’, following the unwillingness of the local district nursing association to adopt it. They also criticised the lack of guidelines from the Local Government Board on the implementation of the scheme.55 By the end of 1917 fifty-two maternal and child welfare schemes had been carried out by twenty-four urban district councils and twenty-eight voluntary agencies while sixteen further schemes had been approved.56 The Local Government Board accepted that ‘much more remained to be done’ with respect to infant mortality.57 The state also introduced measures aimed at improving midwifery provision. The conditions in which Irish women usually gave birth continued to be less than ideal during the war. The maternal mortality rate in the Rotunda Hospital was half that of Dublin city in general during 1915 but in this period maternity hospital confinements were exceptional. The home, no matter how basic, was generally accepted as the proper environment for birth.58 Many working-class women who could not afford a doctor preferred to call on the services of the local ‘handywoman’ rather than the dispensary midwife, but these women were usually untrained and potential carriers of infection from one woman to another.59 Under the Midwives (Ireland) Act passed in 1918, mothers who did not qualify for free treatment under the medical charities system were entitled to medical aid in case of an emergency in connection to parturition. The Act’s main purpose however was to regulate midwifery in

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First World War attitudes to maternal/infant health

Ireland. It made it illegal for women to describe themselves as midwives unless qualified to do so or to attend childbirth other than under the direction of a doctor, unless she was a certified midwife.60 It was hoped that this attempt to replace the use of unqualified handywomen with registered midwives would reduce maternal deaths from infection and accidents of childbirth. However, despite the Act, the handywoman continued to be a regular feature of Irish childbirths until the 1940s.61 The Midwives Act had been passed in England and Wales in 1902 and there had been intensive lobbying by the Irish medical profession to have it extended to Ireland. Concern had been expressed that its implementation in Britain had led to a flood of handywomen from elsewhere in the United Kingdom moving to Ireland and thus increasing ‘the number of these deplorable beings’ operating in Ireland.62 The extension of the 1902 Act to Scotland in 1915 lent further weight to the campaign. This, together with the increased interest in infant and maternal welfare in wartime, led to the Midwives (Ireland) Act eventually being placed on the statute books in February 1918.63 Although undoubtedly of some benefit, the Notification of Births Act (1915) and the Midwives (Ireland) Act merely represented the belated extension of British measures to Ireland rather than any radical new reforms. Wartime mortality trends The increased role of the state in infant and maternal welfare during the First World War is evident. However, what impact did these measures have on mortality rates? How did the war itself affect the survival chances of mothers and infants in Britain and Ireland? The most comprehensive data for assessing infant and maternal mortality rates for the period are the national statistics presented in the annual reports of the Registrar-General for Ireland. Infant mortality rates fell during the war in Ireland and Great Britain, although the extent of that decline varied. The average for the four full years of war (1915– 18) was 87.3 for Ireland compared to 91 for the previous four years, a drop of 4.1 per cent.64 The percentile decline in Scotland for the same period was just 1.8 per cent while the rate for England and Wales dropped by a significant 10.1 per cent. The wartime decline is evident in Table 1.1, which shows the number of infant deaths per 1,000 births in Ireland and Great Britain from 1910 to 1920. The 1916 rate for Ireland – eighty-three deaths per 1,000 births – was the lowest recorded since 1900.65 Although there was a small spike in 1917, there was a clear decline in infant mortality over the following three years, particularly evident when the excessive mortality from the influenza pandemic in 1918 and 1919 is excluded. The primary cause of infant mortality in Ireland during the war continued to be ‘wasting diseases’ forming 40 per cent of all infant deaths between 1915 and 1918. The descriptor ‘wasting diseases’ included

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Table 1.1  Infant mortality rates in Ireland and Great Britain (1910–20) Year

Ireland

England and Wales

Scotland

1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920

95 94 86 97 87 92 83 88 86 88 83

105 130 95 108 105 110 91 97 97 89 80

108 112 105 110 111 126 97 107 100 102 92

Source: Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland (HC 1921 [Cmd.1532] ix.47, p. xviii)

atrophy, marasmus and debility, prematurity and congenital malformations, conditions associated with the health of the mother.66 Diarrhoea was the next single biggest killer forming 13.3 per cent of the average rate.67 Bigger has suggested that inadequate nutrition was responsible for the continuing high death rates from these causes. It was clear to him that the problem of infant mortality was fundamentally one of poverty and that this was an ongoing problem during the war.68 Jay Winter’s work on infant mortality in wartime Britain has noted an improvement in infant survival chances in areas of London that had a particularly high mortality rate before the war.69 How does this compare to Dublin? Comparative examination of Dublin, Belfast, London and Glasgow reveals that the two Irish cities had the highest mortality rates from 1901 to 1920, and that Dublin’s was particularly high. As indicated in Table 1.2, Dublin was the only city of the four where the mortality rate was higher during the war years than the previous four years, an increase of 2.4 per cent. Over the same period, the mortality rate declined in the other three cities examined: by 4.8 per cent in Belfast, 3.8 per cent in London and 5.7 per cent in Glasgow.70 The decline in Belfast, but not Dublin, may be due to the much greater number of war contracts awarded to Belfast manufacturing industries, thus reducing urban unemployment.71 The urban rural divide remained acute. The average rate for the nineteen town districts, with populations over 10,000, was 59.8 per cent greater than that for the remainder of the country: 128.1 deaths per 1,000 births compared to 69.1 deaths.72 There was also a small decrease in the number of maternal deaths associated with pregnancy and childbirth over the war period. The average number of

First World War attitudes to maternal/infant health

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Table 1.2  Comparative urban infant mortality in Dublin, Belfast, London and Glasgow (1912–18) Year

Dublin

Belfast

London

Glasgow

1912 1913 1914 1915 1916 1917 1918

140 153 145 160 153 146 149

129 144 143 137 111 128 142

90 105 104 112 89 107 103

124 129 133 143 111 113 128

Source: Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland (HC 1921 [Cmd.1532] ix.47, p. xx)

such deaths for the war years was 9.7 per cent less than that for the previous four years, falling from 579 to 523 deaths (when excessive deaths from the influenza pandemic are excluded).73 However, this decline may be attributed to the reduced birth rate in wartime. The birth rate fell by 11.6 per cent between 1914 and 1918 in Ireland. Although this was less significant than Britain, where the birth rate fell by 24.1 per cent over the same period, it nonetheless was a noticeable drop.74 Examination of the maternal mortality rate (the number of deaths associated with pregnancy and childbirth per 1,000 of the registered births) reveals a drop of just 0.3 per cent in the death rate for the war years compared to the previous four years when excess influenza mortality in 1918 and 1919 is subtracted.75 There was a small increase in maternal mortality in 1915 and 1916, but the mortality figure for 1917 represents a dramatic decrease and is the lowest recorded that century. The year 1917 was also a particularly low one for British maternal mortality, and Winter has suggested that it may have been partly affected by the lower birth rate.76 The influenza pandemic had a noticeable impact on maternal mortality, forming 10 per cent of all maternal deaths caused by or associated with pregnancy or childbirth in 1919. In contrast influenza was a factor in just 0.4 per cent of all maternal mortality cases in 1917.77 However, deaths from puerperal diseases and accidents of pregnancy and childbirth declined further in 1918 and 1919. Although rates of maternal mortality from childbirth may reflect the extent of obstetric help available as well as the nutritional status of the mother, examination of the specific categories of maternal mortality give some indication of the general health of mothers.78 The primary cause of maternal mortality in Ireland was ‘accidents of pregnancy and childbirth’, forming over 50 per cent of all maternal deaths from 1901 to 1920. The mortality rate from these causes initially increased in 1915 but then began to steadily fall. Puerperal septic

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diseases were the next biggest maternity risk, causing one-third of all deaths associated with childbirth and pregnancy. Its rate rose in 1916 but as with the above-mentioned cause, it began to decline in the last years of the war, with 1919 displaying the lowest rates. The death rate from other causes remained quite steady during the war years but peaked significantly in 1918 and 1919 due to the influenza pandemic.79 The influenza pandemic may also be responsible for the increased deaths from puerperal septic disease in 1920 when the rate reached its highest figure for the decade under consideration.80 A similar rise took place in Britain, and Winter has suggested that women who survived influenza may have had less resistance to complications of pregnancy afterwards. The maternal mortality rate in Great Britain followed a similar trend to that of the pre-war period.81 Infant and maternal mortality figures present a complex and not easily defined picture. Dyhouse has rightly warned of the difficulties of providing a quantitative analysis of mortality trends, noting for example the alterations in the official requirements for the registration of demographic data and a growing sophistication in the diagnosis of various kinds of disease and categorisation of death.82 Nonetheless, the annual national statistics provide some insight into the war’s impact upon the most vulnerable in society and offer a useful comparative between the situation in Ireland and Great Britain. There are indications of some small improvement in Irish annual figures for infant mortality, and maternal mortality in 1917, but the improvement is less significant than in Great Britain. The urban–rural divide remained acute with regard to infant mortality. Survival chances in Dublin continued to be much lower, a situation made worse by the deteriorating housing conditions during the war.83 Conclusion The unprecedented extent of the military loss of lives in the war heightened sensitivities towards death in wartime and brought anxiety about the strength of the nation, resulting in increased concern with infant mortality in Ireland during the First World War. From her study of child welfare in Ireland, Dunwoody has concluded that the war brought the language of social reform but not the reality.84 However, the practical measures introduced during the war years, as outlined above, were of some benefit to mothers and infants. Although contemporaries criticised the educational focus of the welfare movement, there is evidence of a growing recognition of the role of poverty in determining infant mortality rates.85 While somewhat divisive in their appeal, events such as National Baby Week brought the issue into greater prominence and highlighted significant social problems. The belated extension of relevant legislation to Ireland concerning the notification of births and midwifery regulation marked important milestones in infant and maternal care, while the funds provided through the Imperial Treasury for the maternity and child welfare schemes enabled the

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First World War attitudes to maternal/infant health

expansion of the WNHA activities. As noted by Dwork, in relation to similar initiatives in Britain, they were a conservative solution but a relatively successful one.86 The benefits of the infant welfare movement combined with greater employment and agricultural prosperity in wartime can be seen in the small improvement in infant and maternal survival rates during the war. However, the failure to address the serious issue of the deteriorating housing conditions in Dublin was reflected in the city’s persistently high infant mortality rate. Infant welfare became increasingly politicised during the war, with republicans using the issue as part of their argument for Irish independence. Nonetheless the disputes and tensions between the disparate concerned groups may have served to bring more attention to the problem of infant mortality, and increased public interest in the saving of Ireland’s future generations. Notes   1 S. S. Millin, ‘Child life as a national asset’, Journal of the Statistical and Social Inquiry Society of Ireland, 13 (December 1915), 301–16, 307.   2 J. Lewis, The Politics of Motherhood: Child and Maternal Welfare in England 1900–1939 (London: Croom Helm, 1980); D. Dwork, War Is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England, 1898–1918 (London: Tavistock, 1987); V. Fildes, L. Marks and H. Marland, Women and Children First: International Maternal and Infant Welfare 1870–1945 (London: Routledge, 1992).   3 J. Dunwoody, ‘Child welfare’, in D. Fitzpatrick (ed.), Ireland and the First World War (Dublin: Trinity History Workshop, 1986); L. Earner-Byrne, Mother and Child: Maternity and Child Welfare in Dublin 1922–60 (Manchester: Manchester University Press, 2007); I. Miller, Reforming Food in Post-Famine Ireland: Medicine, Science and Improvement 1845–1922 (Manchester: Manchester University Press, 2014), pp. 155–72.   4 B. N. Browne and D. S. Johnson, ‘Infant mortality in interwar Northern Ireland’, in R. Mitchison and P. Roebuck (eds), Economy and Society in Scotland and Ireland 1500–1939 (Edinburgh: John Donald Publishers, 1988), p. 277; C. Clear, Social Change and Everyday Life in Ireland 1850–1922 (Manchester: Manchester University Press, 2007), pp. 98–9.   5 L. Kennedy and L. Clarkson, ‘Birth, death and exile: Irish population history 1700– 1921’, in B. J. Graham and L. J. Proudfoot (eds), An Historical Geography of Ireland (London: Academic Press, 1993), p. 171.   6 J. Bourke, Working Class Cultures in Britain, 1890–1960: Gender, Class and Ethnicity (London: Routledge, 1994), p. 8.   7 Women’s National Health Association of Ireland: Golden Jubilee 1907–1957 (Dublin: Women’s National Health Association, 1958), p. 1.   8 Earner-Byrne, Mother and Child, p. 15.   9 Miller, Reforming Food in Post-Famine Ireland, p. 157. 10 E. Coey Bigger, Carnegie United Kingdom Trust: Report on the Physical Welfare of Mothers and Children, IV, Ireland (Dublin: Carnegie United Kingdom Trust, 1917), p. 74. 11 C. Dyhouse, ‘Working-class mothers and infant mortality in England, 1895–1914’, in C. Webster (ed.), Biology, Medicine and Society 1840–1940 (Cambridge: Cambridge University Press, 1981), p. 74.

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Health and disease on the domestic front 12 Ibid., pp. 75–6. 13 F. Moore, ‘Governmentality and the maternal body: infant mortality in early twentieth-century Lancashire’, Journal of Historical Geography, 39:1 (January 2013), 54–68, 59; T. J. Hatton, ‘Infant mortality and the health of survivors: Britain, 1910–50’, Economic History Review, 64:3 (August 2011), 951–72, 952. 14 Moore, ‘Governmentality and the maternal body’, 55; Miller, Reforming Food in Post-Famine Ireland, p. 156. 15 Lewis, Politics of Motherhood, p. 67. 16 Miller, Reforming Food in Post-Famine Ireland, p. 157. 17 Ibid., pp. 156–8. 18 G. Robb, British Culture and the First World War (Basingstoke: Palgrave Macmillan, 2002), p. 80. 19 Dwork, War Is Good for Babies, p. 208; Dyhouse, ‘Working-class mothers’, p. 73. 20 Lewis, Politics of Motherhood, p. 27. 21 Bigger, Carnegie United Kingdom Trust, p. 2. 22 Forty-Sixth Annual Report of the Local Government Board for Ireland, HC 1919 [Cmd.65] xxv.1, p. 57. 23 Irish Homestead (9 June 1917), p. 428. 24 Millin, ‘Child life as a national asset’, 301–16. 25 W. Lawson, ‘Infant mortality and the notification of births Acts, 1907, 1915’, Journal of the Statistical and Social Inquiry Society of Ireland, 13 (November 1917), 579–97, 579. 26 Bigger, Carnegie United Kingdom Trust, p. 2. See for example, Church of Ireland Gazette (6 July 1917), p. 477; Lady of the House (14 July 1917), p. 9; Irish Homestead (22 September 1917), p. 705. 27 Weekly Irish Times (7 July 1917), p. 6. 28 Lady of the House (14 July 1917), p. 9. 29 Irish Times (1 June 1917), p. 4. 30 Irish Homestead (22 September 1917), p. 705. 31 Church of Ireland Gazette (6 July 1917), p. 477; Lady of the House (14 July 1917), p. 9. 32 D. Fitzpatrick, ‘The logic of collective sacrifice: Ireland and the British Army 1914–1918’, Historical Journal, 38:4 (December 1995), 1017–30, 1025; D. Fitzpatrick, ‘Protestant depopulation and the Irish revolution’, Irish Historical Studies, 38 (November 2013), 643–70, 659. 33 Lady of the House (15 January 1917), p. 3. 34 Lady of the House (15 August 1917), p. 5. 35 Irish Citizen (October 1919), p. 39; Irish Citizen (September 1917), p. 378; Irish Citizen (December 1917), p. 389. 36 Irish Citizen (October 1919), p. 392. 37 New Ireland (26 October 1918), p. 392. 38 Miller, Reforming Food in Post-Famine Ireland, p. 165. 39 Bodleian Library, Nathan papers, ‘Memorandum 469’, 4 November 1915. 40 Ibid., 12 January 1916. 41 New Ireland (26 October 1918), p. 392. 42 M. Keane, Ishbel: Lady Aberdeen in Ireland (Newtownards: Colourpoint Books, 1999), pp. 157–60. 43 Irish Citizen (July 1917), p. 307; Irish Citizen (August 1917), p. 373; Irish Citizen (September 1917), p. 378. 44 Irish Citizen (August 1917), p. 373. 45 New Ireland (26 October 1918), p. 392. 46 Lawson, ‘Infant mortality and the notification of births Acts’, 493.

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First World War attitudes to maternal/infant health 47 Journal of the Department of Agriculture and Technical Instruction Volume Seventeen (Dublin: HMSO, 1917), p. 146. 48 For the history of the milk supply problems, see Miller, Reforming Food in PostFamine Ireland, p. 159. 49 Irish Homestead (10 July 1915), p. 450; Irish Homestead (30 October 1915), p. 719; Irish Homestead (15 July 1916), p. 441; Irish Homestead (20 January 1917), p. 40; Irish Homestead (21 April 1917), p. 289; Irish Homestead (30 June 1917), p. 485; Irish Homestead (14 July 1917), p. 522; Irish Homestead (25 August 1917), p. 644; Catholic Bulletin (November 1918), p. 548; Lady of the House (15 November 1917), p. 22. 50 Irish Times (3 July 1917), p. 6. 51 Irish Homestead (21 April 1917), p. 289. 52 Earner-Byrne, Mother and Child, p. 10. 53 Forty-Fifth Annual Report of the Local Government Board for Ireland, HC 1917–18 [Cd. 8765] xvi.257, p. 56. 54 Forty-Sixth Annual Report of the Local Government Board, p. 56. 55 Leinster Leader (21 July 1917), p. 3; Leinster Leader (18 August 1917), p. 4; Leinster Leader (25 August 1917), p. 4; Leinster Leader (16 February 1918), p. 2. 56 Forty-Sixth Annual Report of the Local Government Board, p. 58. 57 Ibid. 58 J. Robbins, ‘Public policy and the maternity services in Ireland during the twentieth century’, in A. Browne (ed.), Masters, Midwives and Ladies-In-Waiting (Dublin: A. and A. Farmar, 1995), pp. 278–9. 59 Bigger, Carnegie United Kingdom Trust, p. 24. 60 Robbins, ‘Public policy and the maternity services’, p. 282. 61 C. Clear, Women of the House: Women’s Household Work in Ireland 1922–1961 (Dublin: Irish Academic Press, 2000), p. 104. 62 See, for example, Church of Ireland Gazette (1 September 1916), p. 620; Irish Citizen (October 1916), p. 231; Irish Citizen (April 1917), p. 258. 63 A. McMahon, ‘Regulating midwives: the role of the R. C. P. I’, in G. M. Fealy (ed.), Care to Remember: Nursing and Midwifery in Ireland (Cork: Mercier Press, 2005), pp. 167–71. 64 Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland, HC 1921 [Cmd.1532] ix.47, p. xviii. 65 Fifty-Fifth Detailed Annual Report of the Registrar-General for Ireland, HC 1919 [Cmd.450] x.849, p. xxix. 66 Lewis, Politics of Motherhood, p. 31. 67 Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland, p. xviii. 68 T. Farmar, Holles Street 1894–1994: The National Maternity Hospital – A Centenary History (Dublin: A. and A. Farmar, 1994), pp. 60–1. 69 J. M. Winter, ‘Public health and the political economy of war 1914–1918’, History Workshop, 26 (Winter 1988), 163–73, 164. 70 Fifty-First Detailed Annual Report of the Registrar-General for Ireland, HC 1914–16 [Cd.7991] ix.687, p. xl; Fifty-Third Detailed Annual Report of the Registrar-General for Ireland, HC 1917–18 [Cd.8647] vi.585, p. xxxii; Fifty-Fifth Detailed Annual Report of the Registrar-General for Ireland, p. xxix; Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland, p. xx. 71 N. Puirseil, ‘War, work and labour’, in J. Horne (ed.), Our War: Ireland and the Great War (Dublin: Royal Irish Academy, 2008), p. 184. 72 Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland, p. xx. 73 Ibid., p. xv. 74 B. R. Mitchell, Abstract of British Historical Statistics (Cambridge: Cambridge University Press, 1962) pp. 30–3.

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Health and disease on the domestic front 75 To alleviate the distorting impact of the influenza pandemic in 1918 and 1919, I have subtracted the deaths from influenza for those years and replaced them with the average for the previous ten years. 76 J. M. Winter, The Great War and the British People (London: Macmillan, 1985), p. 134. 77 Fifty-Forth Detailed Annual Report of the Registrar-General for Ireland, HC 1918 [Cd.9123] vi.357, p. xxv; Fifty-Fifth Detailed Annual Report of the Registrar-General for Ireland, p. xxv; Fifty-Sixth Detailed Annual Report of the Registrar-General for Ireland, HC 1920 [Cmd.997] xi.620, p. xxvi. 78 R. Millward and F. Bell, ‘Infant mortality in Victorian Britain: the mother as medium’, Economic History Review, 54:4 (November, 2001), 699–733, 714. 79 Fifty-Seventh Detailed Annual Report of the Registrar-General for Ireland, p. xv. 80 The vulnerability of pregnant women to the influenza epidemic is discussed in C. Foley, The Last Irish Plague: The Great Flu Epidemic in Ireland 1918–19 (Dublin: Irish Academic Press, 2011) pp. 34–5. 81 Winter, The Great War, p. 134. 82 Dyhouse, ‘Working-class mothers’, p. 77. 83 I. Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality (Oxford: Oxford University Press, 1992), p. 241. 84 Dunwoody, ‘Child welfare’, p. 75. 85 For example, see Forty-Sixth Annual Report of the Local Government Board for Ireland, p. 58. 86 Dwork, War Is Good for Babies, p. 211.

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2

The war and influenza: the impact of the First World War on the 1918–19 influenza pandemic in Ulster Patricia Marsh

The last six months of the First World War coincided with one of the most virulent pandemics of the twentieth century. Dubbed ‘the Spanish flu’, it struck in three concurrent waves throughout the world and may have had a global mortality of 100 million.1 There were three distinct waves of influenza in Ireland, which occurred in June 1918, October 1918 and February 1919. An estimated 800,000 Irish people may have been infected by the disease,2 with at least 23,000 fatalities during 1918 and 1919.3 A contemporary Ministry of Health report on the influenza pandemic in the United Kingdom, published in 1920, stated that ‘it will be seen that the Irish influenza did not present, either in respect of prevalence or severity, any uniform variation from the type dominant in England and Wales’. The author of the report expressed surprise from an epidemiological stance as ‘from the point of view of material wellbeing, the reaction of the war upon the Irish population was less prejudicial than in other divisions of the United Kingdom, and both the age and sex constitution and housing aggregation were not forced so far from the normal equilibrium’.4 Evidently, it was the author’s belief that influenza and war were somehow interconnected. In his view, Ireland’s relative isolation from the war should have sheltered the country not only from the effects of the conflict, but also influenza. This raises the question of whether Irish wartime health was really as safeguarded as the author suggested. Catriona Foley and Ida Milne have both explored the Irish experience of influenza. Milne examines influenza in Ireland with a specific focus on Leinster,5 while Foley gives an overview of Ireland, focusing mainly on the political and social landscape in the southern counties of the country. Both authors strongly demonstrate that influenza had a major impact on contemporary Irish society. Ulster (relatively unexplored by Milne and Foley) was in a unique position in Ireland as the industrial centre of the country with the north-east of the

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province bearing closer resemblance to the more industrial regions in Britain than with other parts of Ireland. The majority of local authorities in the province were Unionist and pro-war. Thus the Ulster experience of influenza bore many similarities to the rest of the United Kingdom and was more influenced by the war. This chapter explores the likelihood that war played an important part in introducing influenza and its subsequent spread throughout Ulster and Ireland, especially during the first wave. In addition, it argues that war suppressed contemporary reporting of the disease in Ulster, which in turn could have contributed to a subsequent amnesia of this pandemic in the province. It also demonstrates that the First World War impacted on both the medical and welfare response to influenza due to shortages of both medical personnel and hospital accommodation during the outbreaks of this virulent disease. This chapter recognises the influence that government decisions in the United Kingdom had upon all of Ireland. Accordingly, it discusses the lack of government recommendations on prevention of the disease due to other wartime priorities and maintains that this had a similarly profound detrimental effect in Ulster as in the rest of the United Kingdom. Origins and dispersal of influenza in Ireland The first reported influenza outbreak in Ireland was at a naval base in Queenstown (now Cobh) in Cork in May 1918, where seventy-seven influenza cases occurred on the USS Dixie, which was stationed there.6 These initial influenza cases appeared to be confined to the Dixie crew. However, it is evident that the first influenza outbreak in Ireland actually occurred in Belfast. The Local Government Board for Ireland (LGBI) report, which covers the period up to the end of March 1919, suggested that the first wave of influenza was principally in Belfast and other districts of the north of Ireland.7 First reports of the disease in Belfast surfaced as early as 11 June 1918 when a notice appeared in local newspapers regarding the reopening, after influenza, of a department in James Mackie and Sons munitions factory. Newspapers also reported a number of quarantined military cases in the city.8 The Belfast Public Health Department annual report for 1918 confirmed that the first influenza outbreak in the city occurred between 15 June and 27 July 1918, peaking on 29 June 1918.9 It seems that influenza spread eastwards to Holywood, Co. Down, by 15 June 1918,10 reaching Bangor by the end of the month.11 From Belfast, influenza also spread south-west to Lisburn district and Lurgan in June 1918.12 Londonderry with its own port and shipyards was also affected. Moreover, the town had the highest mortality in Ulster from pneumonia, which was considered to be the most serious complication associated with influenza.13 Although the main outbreak was in Ulster, influenza broke out sporadically in other parts of Ireland during June and early July 1918; namely Ballinasloe,

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The war and influenza

Dublin, Tipperary, Athlone and Cork.14 Significantly, most of these outbreaks were located in close proximity to an army or naval base. Influenza within the military camps was rife. The report of the medical and sanitary work of the Ulster Brigade confirms that during June and July 1918 there were approximately 5,000 influenza cases in the military hospitals in Ulster, located in Belfast, Armagh, Enniskillen, Holywood, Londonderry, Omagh, Newry, Donegal, Dundalk and Drogheda. All were proportionately affected. In Cork and District, eighty-seven soldiers with influenza were admitted to the Queenstown military hospital between 26 June and 27 July. In July, 119 were admitted to Cork military hospital.15 Although towns such as Lisburn, Lurgan and Bangor did not have a military base nearby, they were serviced by railway from Belfast. There is little doubt that the first wave of influenza entered Ireland via Belfast, probably with returning troops in early June and then spread to various Ulster towns via their travel using the rail system. Meanwhile, outbreaks occurred in other Irish towns with military connections adding to the speculation that troop movement was instrumental in the spread of influenza. The second wave in Ireland originated in Leinster with reports as early as 1 October 1918 of an outbreak of severe influenza in the Howth district of Dublin.16 The pneumonia mortality figures show that Dublin was the first major Irish city affected. Deaths from the disease began to increase around 12 October.17 It should be noted that all sick and wounded soldiers returning from overseas to Ireland landed off the hospital ships at the Dublin port from France or England. From Dublin they were transported to Belfast by ambulance train and then conveyed to the various Ulster military hospitals by motor ambulances and private cars.18 Influenza spread throughout Leinster, to Dundalk, Drogheda, Wexford and Kilkenny by the end of October.19 It is noteworthy that there was a military hospital situated in Dundalk and the 2nd King Edward’s Horse regiment was based in Kilkenny. Influenza in Ulster was first reported in Larne on 9 October20 where there was a Royal Naval base at the port. This may have accounted for its early appearance in the town. Influenza was prevalent in Holywood at least a week before it appeared in Belfast at the end of the month.21 The presence of an army barracks and military hospital near Holywood may account for this. This second virulent influenza outbreak seemed to enter Ireland via Dublin and made its way through Leinster, eventually spreading northwards to Belfast. In all probability, troops were instrumental in this. First reports of the third wave were again in Leinster in Co. Kildare. By 12 February 1919 influenza had spread to Dublin.22 The disease was first reported in Belfast at the Board of Guardians’ meeting on 18 February23 and this was the mildest wave of influenza in the city.24 In the same month a recurrence of influenza was reported in Co. Donegal in Ballyshannon and Pettigo. This severe outbreak along the north-east seaboard of Co. Donegal,

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especially in Falcarragh, was attributed to a large number of demobilised soldiers returning home.25 In March 1919, there were reports of several influenza deaths in the vicinity of Ballykinlar camp in Co. Down.26 Although the war was over by the time the third wave began in February 1919, a suspicion existed that influenza was being spread by demobilised soldiers. Mark Honigsbaum has argued that troop movement from America was instrumental in introducing influenza to the Western Front. Subsequently, soldiers brought the disease from France to Britain via Portsmouth and other ports, from where it was carried by rail to infect major cities such as London, Birmingham and Liverpool.27 Foley suggests that troops played a notable role in introducing and disseminating the disease in Ireland. Evidently, the manner in which influenza spread throughout Ireland during all waves of the pandemic suggests that it entered the country in a similar way to that in mainland Britain: via naval bases, army hospitals or barracks, with military personnel returning home to convalesce in the various military hospitals or through demobilisation after the war. It then spread through the movement of soldiers and civilians across the country via the railway network. Media representations of influenza in Ulster During the pandemic Ulster newspapers adopted different narratives and themes that were influenced by the war and contemporary political concerns peculiar to Ireland. Articles published in June and July 1918 in the nationalist newspapers Irish Independent, Frontier Sentinel and Derry Journal typically described influenza as mysterious, a plague or scourge.28 Some Irish nationalist and Sinn Féin newspapers seized upon the uncertainty and fear about influenza, especially during the first wave. In June, nationalist newspapers including the Irish News and Derry Journal implied that influenza was ‘trench fever’, a disease caused by lice to soldiers in the trenches during the First World War.29 Although this theory was subsequently rejected by doctors, the appearance of influenza in Irish towns coincided with the return of discharged soldiers, which added validity to the newspapers’ claims.30 In July, the Irish News intimated that influenza was directly associated with war, describing it as a ‘virulent infectious poison’. A journalist quoted a Dublin military doctor (home on leave) who claimed that influenza symptoms were similar to those of soldiers suffering from gas poisoning in the trenches.31 During the second wave, the Derry Journal suggested that the suddenness of the disease raised questions as to whether it was influenza at all. It stated ‘it is supremely tragic to find that a colossal toll in human lives is being taken through a disease called influenza, doubtless for want of a name to specify it with more exactitude’.32 During 1918 and 1919 a large increase in venereal disease was reported in Ireland.33 Sinn Féin, as part of their anti-conscription campaign, directly associated the dangers of venereal disease with soldiers returning to Ireland. Kathleen

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Lynn, Director of Public Health for Sinn Féin and an active anti-conscription supporter, blamed the British Army for the spread of venereal disease.34 The anti-conscription campaign was one that united both Sinn Féin and the Irish Parliamentary Party during this period.35 Therefore, the insinuation by nationalist newspapers that war and returning troops brought infections such as venereal disease and the ‘mystery illness’ of influenza helped increase the suspicion of soldiers and bolstered the fear of conscription, with the suggestion that healthy Irishmen would be sent to war only to return with the disease. Significantly, newspapers with Unionist sympathies such as the County Down Spectator, Belfast News-Letter and Northern Whig also questioned the origin and nature of influenza especially during June 1918. However, unlike the nationalist newspapers, they criticised public overreaction to the disease.36 Although it was true that the war facilitated the spread of influenza, Jay Winter argues that it was not a factor in the virulence of the disease.37 However, it has been suggested that the ecological conditions in the trenches could have caused the virus responsible for the first wave to mutate and cause the emergence of the second, more virulent strain.38 Consequently, it would be unfair to totally dismiss the nationalist newspapers’ scepticism about influenza and associations with the war as unfounded. During the first wave some provincial Unionist-run newspapers in Ulster failed to mention influenza at all. Silence in local newspapers can, perhaps, be attributed to influenza not having affected that particular town or to staff shortages due to the disease, which meant that newspapers were sometimes unable to produce their full weekly editions.39 Nevertheless, the silence in some of these Unionist newspapers may have been an attempt to minimise the ravages of the disease locally to raise morale and help the war effort. Undoubtedly it was important not to create panic during a time of conflict. This situation is comparable to the publication of Charles Graves’s history of the Spanish Influenza pandemic, Invasion by Virus, which was postponed in 1958 due to the outbreak of Asiatic flu in 1957. It was eventually published in 1969, but only after the 1968 Hong Kong influenza was found not to be a major killer. As Graves stated in his ‘foreword’, ‘no publisher in his right senses would have dared to face charges of frightening the public still further than it had already been by the newspaper reports’.40 Another way to raise wartime morale was to report the severity of influenza in Germany and Austria, while minimising its death toll and threat in Britain.41 Niall Johnson argues that contemporary reportage of the pandemic in British newspapers focused attention on reports in foreign countries (especially those which were not considered to be allies) rather than reports of the disease in Britain.42 First mentions of influenza in Irish newspapers appeared in late May and early June 1918 and referred to the disease in Spain.43 However, in June 1918, the Unionist Belfast News-Letter reported that influenza was rife in Berlin towards the end of an article reporting its spread in Belfast.44 Between 3 and

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9 July 1918 the Unionist Irish Times, along with reports on influenza in Ireland, produced daily articles on how the disease was reaching epidemic proportions in both Germany and Austria.45 In late June, the Unionist Portadown Express implied that influenza was imported from Berlin to the German lines of the Western Front by soldiers returning from leave.46 In the same month, the County Down Spectator reported – somewhat inaccurately – that influenza was ‘working great havoc in the German trenches’ but that it had not appeared in British and American camps or trenches.47 During the second wave, although references to Germany were less apparent, there were occasionally columns of reports on local outbreaks of influenza that would be completed with an account on the seemingly large casualties in either Austrian or German cities.48 Interestingly, most of the German associations were made before the Armistice on 11 November 1918.49 The press in other parts of the United Kingdom also took this stance. During the first wave, several articles in The Scotsman reported large influenza causalities in Germany, while minimising the local impact of the disease.50 Johnson notes that during this wave articles about influenza in mainland Britain were low-key and that from July 1918, the daily reports on influenza in The Times were mostly linked to foreign locations.51 According to Debra Blakely, American newspapers such as the New York Times also focused on influenza as a ‘German sickness’. Blakely suggested that when influenza epidemics in foreign countries were reported as being more severe, this indirectly associated the blame for the disease on the said foreign country.52 Therefore, Unionist newspapers in Ulster, like their counterparts in mainland Britain, placed emphasis on German cities as both the source and disseminator of influenza; they associated the disease with the wartime enemy – Germany. These newspapers reported influenza in a similar fashion to that of the rest of Britain and, like their British counterparts, downplayed the extent or virulence of the disease locally to boost morale. During the ‘swine flu’ outbreak in 2009, numerous sensational articles about this disease appeared in Irish newspapers,53 which created concern and panic among some of the population about a pandemic that did not occur. In fact, it has been suggested that the virulence of the 1918–19 pandemic is used as an example to cause alarm when reporting current virus-borne catastrophes.54 It is perhaps due to this that news coverage of swine flu in 2009 was so extensive while, ironically, contemporary news coverage of Spanish influenza was sparse. The 1918–19 influenza pandemic has been described as the ‘forgotten pandemic’,55 and there are many reasons why this health catastrophe was globally forgotten. Undoubtedly, the First World War contributed to worldwide amnesia of the disease, and theories regarding the absorption of the event into the collective memory of the war have validity.56 Phillips and Killingray have suggested that because the pandemic occurred at the climax of the First World War – with its massive death toll – influenza has been overshadowed by these events.57 In addition, influenza was an infrequent

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disease which struck suddenly, caused havoc and then just as mysteriously disappeared.58 Closer to home, political upheaval in Ireland during this period – and subsequently – overshadowed the journalistic representations of influenza. Additionally, the complex political allegiances of the time may explain the way in which the disease was framed historically. Janice Hume has argued that mass media had an important role in building public consciousness of an event and that the lack of publicity regarding the pandemic in the American press was an important factor as to why influenza was forgotten in that country.59 In general, coverage of the pandemic in Ulster newspapers was sparse. The pandemic received relatively little press coverage when compared to other burning issues of the day, such as the war and the general election in December 1918, which appeared to take priority in all newspapers. This was evidenced by a letter in the Irish Independent from a correspondent in Co. Mayo, which complained that while influenza raged along the western seaboard, the metropolitan and provincial papers were preoccupied with electioneering propaganda meaning that ‘this pestilential epidemic is now relegated to the status of stale unimportant news’.60 The lack of publicity about influenza in the contemporary newspapers meant that the disease did not infiltrate the public consciousness to any great extent as news of the war and general election were given more column inches and thus importance. Therefore, it is reasonable to assume that the paucity of press coverage, along with other factors, may have played a part in the Irish amnesia to influenza during this period. Official responses to influenza in Ulster The official response to influenza in Ulster was lacklustre, which was hardly surprising as, throughout the United Kingdom, central government gave little support or advice to local authorities on how to combat the disease. Arthur Newsholme was chief medical officer for the Local Government Board (LGB) from 1908 to 1919 and in charge during the pandemic. He, along with the LGB, came under criticism for lack of action especially during the first wave. Newsholme acknowledged that more could have been done during this wave. Measures such as isolating the sick from the healthy, prevention of mass migrations and overcrowding should have been implemented but he believed that this had not been possible due to the demands of war as ‘it was necessary to carry on and the relentless needs of warfare justified incurring the risk of spreading infections’.61 In fact, it was not until 15 November 1918, after the Armistice, that the LGB issued any recommendations on influenza in the form of a memorandum. This was circulated throughout the United Kingdom to all medical officers of health and also to the LGBI. The LGBI acted on instruction from the LGB in London, meaning little advice or support was given to local authorities in Ireland.

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Measures taken by the LGBI included allowing local authorities to employ additional medical and nursing assistance and recommending that county councils allow their tuberculosis officers to undertake the duties of district medical officers if required. Although they considered the possibility of adding influenza to the list of notifiable diseases, it was decided for various reasons that this measure would not stop the spread of the disease. They did however extend the Infectious Disease (Notification) Act to include septic pneumonia: a course of action adopted in Ulster by Larne and Belfast councils during the second wave. In 1919, the LGBI recommended the notification of acute primary pneumonia and acute influenza pneumonia – among other more exotic diseases such as malaria and trench fever consequent on the demobilisation and return of troops serving abroad.62 Although most local authorities recommended the closure of day, Sunday and technical schools, they lacked the authority to make it compulsory. Several councils wanted to close cinemas to the public, but again this action was not sanctioned by the LGBI.63 In reality official bodies provided little support to Irish local authorities for combating influenza. Most left the decisions of coping with the disease to their medical officers of health, with varying results. Another problem faced locally was the lack of both hospital accommodation and medical personnel to treat those suffering from influenza. During this period, many civil medical institutions in Ireland acted as auxiliary military hospitals and it was common for the military to requisition workhouses for the treatment of soldiers.64 This could have caused difficulties when it came to treating the local poor. It has been argued that in mainland Britain, the War Office was widely criticised with respect to hospital accommodation as there was dissatisfaction about the lack of adequate provision for civilians.65 The acquisition of Strabane workhouse by the military prior to the influenza outbreak in the town in October 1918 meant that most of the inmates were sent to the Londonderry workhouse. Charles Browne, the chairman of the Strabane council, requested that the guardians take immediate action to help the ‘suffering poor of the town’. Although the Strabane fever hospital was reopened to the public by 12 November, in the intervening time sick cases from the Strabane union district were sent to Castlederg, Londonderry and Stranorlar workhouses.66 The redirection of the sick from Strabane to the Londonderry Union infirmary caused overcrowding problems in the institution. In November, a sick child transferred from Strabane died from diphtheria because he was left for an hour and a half in the hall of Londonderry Union awaiting medical attention. His death was attributed to both the lack of accommodation at the institution and the unavailability of a doctor to treat him.67 In other words, the child died from neglect as a result of the infirmary being overcrowded and under-resourced. Overcrowding problems in Londonderry Union due to the redirection of patients from Strabane continued. During March 1919, the workhouse medical officer (MO) requested that Strabane

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patients be returned to their own union hospital due to overcrowding in the Londonderry infirmary. However, this practice continued until May when the military eventually evacuated Strabane workhouse.68 Consequently, the Londonderry workhouse infirmary suffered overcrowding problems during the second and third influenza outbreaks that would have only had an adverse effect on the local poor. In Omagh the workhouse MO faced difficulties in housing influenza patients due to the military’s occupation of two wards of the workhouse. The influenza sufferers were forced to share the same isolation wards as those with infectious diseases in the fever hospital. This was not an ideal situation for any of the patients. The military refused the guardians’ request to relinquish the wards for influenza cases, as they were fully occupied by convalescing troops.69 Not all Unions were happy to accommodate the military. In April 1918, the Downpatrick guardians agreed unanimously that they would no longer admit military patients, as they had been treating them at a financial loss for some time. They later rescinded the decision on appeal from the military. Nevertheless, it appeared that during this period, some boards of guardians considered the treatment of military patients to be more important than caring for the local poor. This may have been due to patriotic fervour on behalf of some of the boards. Unionist-run boards of guardians, such as Newtownards, happily accommodated the military.70 Moreover, in some cases the guaranteed fees the guardians received from the military was a welcome and constant source of income.71 The shortage of suitable medical personnel also had a detriment impact on influenza patients. The LGBI noted that Irish dispensary doctors made over 100,000 more home visits to patients during 1918 and 1919, compared to the previous twelve months, indicating that doctors were under severe work pressure during this pandemic. A scarcity of temporary doctors throughout Ireland added to the problem as large numbers of medical practitioners were serving with His Majesty’s Forces. As mentioned, the military could be inflexible, especially with respect to clearing workhouse accommodation used for the treatment of soldiers. However, the LGBI acknowledged that ‘the military authorities, at our request, released for local services during the outbreak a number of practitioners that had just been granted temporary commissions’. Nevertheless, doctors were in short supply, as were nurses. The joint appeal of patriotism and higher salaries had attracted professional nurses to both the army and naval medical corps. The LGBI noted that the nursing staff in Irish medical institutions was considerably depleted because of high wartime demand for their professional services.72 As a result, poor law infirmaries struggled to ensure that they were adequately staffed, especially if medical personnel, particularly nurses, contracted influenza themselves. The importance of qualified and competent nurses, both at home and on the Western Front, should not be underestimated. There was no cure for influenza, so realistically the only

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practical aid that could be given to a patient was to nurse them while they were ill. According to Carol Byerly, nurses were so important during the height of the pandemic that in October 1918, General John Pershing, commander of the American Expeditionary Force in Europe, requested 1,500 nurses rather than the equivalent number of doctors to be sent to France.73 The scarcity of nurses was not only because of their presence at the Western Front, but also due to illness from influenza. In Ulster, many union infirmaries encountered difficulties finding replacement nurses. During November 1918, the clerk of Londonderry workhouse could only enlist the services of one additional temporary nurse and ‘two capable women to accompany the ambulance and assist as ward maids in the infirmary’.74 In December, along with the forty-one influenza patients, three nurses were absent with the disease at Ballycastle infirmary and fever hospital. The MO was forced to retain the services of two volunteers, who held St John Ambulance Society certificates to replace the absentees due to the lack of professional nurses.75 Elsewhere in Ireland, the situation was similar. A doctor in the Dublin Mater Hospital recollected that many nurses suffered from influenza and pneumonia, requiring treatment in the nurses’ home.76 According to Foley, there was a shortage of nurses throughout Ireland, so volunteers, particularly nuns, helped to nurse influenza patients.77 It is apparent that the scarcity of medical personnel and the lack of suitable accommodation resulted in hardship for the sick poor suffering from influenza during this period. The Western Front attracted nurses and doctors alike creating a shortage of trained personnel to treat the sick poor. Also, the requisition of civil hospitals and workhouse infirmaries by the military for housing convalescing soldiers seemed to be of higher priority to the guardians than treating the local poor. Conclusion There is no doubt that soldiers returning to various Irish hospitals and barracks were instrumental in introducing influenza to Ireland and subsequently spreading it throughout the country. Contemporary newspaper coverage of influenza in Ulster was sparse compared to articles on the war and, during the second wave, the 1918 general election (during which Sinn Féin overwhelmingly defeated the Irish Parliamentary Party nationwide, but not in Ulster). Wartime censorship and the intention to boost morale to help the war effort may also have influenced the way the disease was reported in Ulster. Nevertheless, the paucity of influenza-related articles in Ulster newspapers may have had the effect of removing the pandemic from the collective memory of the population and could account for the amnesia with respect to the disease for so many years. This demonstrates that the unique political culture of Ireland during the First World War had an impact on representations, public perceptions and responses to diseases during a period of international crisis.

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The war and influenza

The need to help the war effort in Britain and Ireland also influenced how the central government responded to influenza, as little advice or support was forthcoming for local authorities from the LGB. Medical care of influenza sufferers was hampered by the lack of suitable hospital accommodation married with the scarcity of doctors and nurses to treat the disease at a local level. Some local authorities and boards of guardians, especially in Ulster, appeared to rate the health of convalescing soldiers as more important than that of their local poor, revealing one of the ways in which war disrupted health provision on the Irish domestic front. Civil hospitals, Union infirmaries, and wards therein, were requisitioned by the military, sometimes to the detriment of the poor. Added to this was the shortage of medical personnel, many of whom were serving on the Western Front. So although the 1920 Ministry of Health report suggested that the impact of the war was ‘less prejudicial’ to the Irish population than that of the rest of the United Kingdom,78 the evidence shows that the war also had a profound detrimental effect on Ulster during the 1918–19 pandemic.

Notes   1  N. Johnson and J. Mueller, ‘Updating the accounts: global mortality of the 1918– 1920 “Spanish” influenza pandemic’, Bulletin of the History of Medicine, 76:1 (spring 2002), 105–15, 115.   2  I. Milne, ‘Epidemic or myth? The 1918 flu in Ireland’ (master’s dissertation, National University of Ireland, Maynooth, 2005), p. 35.   3  P. Marsh, ‘The effect of the 1918–19 influenza pandemic on Belfast’ (Master’s dissertation, Queen’s University, Belfast, 2006), p. 42.   4  Ministry of Health, Report on the Pandemic of Influenza, 1918–19 (London: HMSO, 1920), p. 54.   5  I. Milne, ‘The 1918–19 Spanish flu epidemic in Leinster’ (Ph.D. dissertation, Trinity College Dublin, 2011). C. Foley, The Last Irish Plague: The Great Flu Epidemic in Ireland, 1918–19 (Dublin: Irish Academic Press, 2011).   6  United States Navy Department, Annual Report of the Secretary of the Navy, Miscellaneous Reports (Washington, DC: Government Printing Office, 1919), pp. 2423–4.   7  Forty-Seventh Annual Report of the Local Government Board for Ireland, HC 1920 [Cmd 578] xxi.1, p. xxxvii.   8  Belfast Telegraph (11 June 1918), p. 3; Irish Independent (11 June 1918), p. 3; Belfast News-Letter (12 June 1918), p. 6.   9  Belfast News-Letter (28 December 1918), p. 3. 10  Public Record Office for Northern Ireland (hereafter PRONI) LA/38/9AA/3, ‘Holywood Urban District Council: Holywood Public Health Committee Meeting’, 4 July 1919. 11  PRONI, LA/20/9AA/5, ‘Bangor Urban District Council: Bangor Public Health Committee Meeting’, 2 July 1918. 12  PRONI, LA/48/9AB/6, ‘Lisburn Urban District Council Monthly Report: Lisburn Medical Officer of Health Report’, 1 July 1918; PRONI, LA/51/9D/6, ‘Lurgan Medical Officer of Health Report: Lurgan Medical Officer of Health Report’, 1 July 1918.

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Health and disease on the domestic front 13  Weekly Returns of Births and Deaths in the Dublin Registration Area and in Eighteen of the Principal Towns in Ireland 1918 (Dublin: HMSO, 1919) 14  Irish Independent (20 June 1918), p. 2; Irish Independent (24 June 1918), p. 2; Irish Independent (25 June 1918), p. 2; Nenagh Guardian (6 July 1918), p. 4. 15  National Archives, Kew (hereafter Kew), WO35/179/4, ‘Historical Records: Calls for Historical Review of the Medical and Sanitary Work in the Irish Command during the Period of the War: Report of the Medical and Sanitary work of the Ulster Brigade’, p. 4; Historical Review of the Medical and Sanitary Work of the Cork District during the War Period’, p. 5. 16  Irish Independent (1 October 1918), p. 3. 17  Weekly Returns of Births and Deaths in the Dublin Registration Area. 18  Kew, WO 35/179/4, ‘Historical Records: Calls for Historical Review’, p. 3. 19  Irish Independent (25 October 1918), p. 4. 20  PRONI, BG/17/A/132, Larne Union Minute Book 1918, ‘Larne Board of Guardians Meeting’, 9 October 1918. 21  PRONI, LA/38/9AA/3, ‘Holywood Urban District Council: Holywood Public Health Committee Meeting’, 7 November 1918. 22  Irish Independent (5 February 1919), p. 4; Irish Times (12 February. 1919), p. 4. 23  PRONI, BG/7/A/101, ‘Belfast Union Minutes: Belfast Board of Guardians Meeting’, 18 February 1919. 24  Marsh, ‘Effect of the 1918–19 influenza pandemic on Belfast’, pp. 66–7. 25  Irish Independent (17 February 1919), p. 2. 26  Belfast News-Letter (12 March 1919), p. 8. 27  M. Honigsbaum, Living with Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918 (London: Macmillan, 2009), pp. 45–50. 28  Frontier Sentinel (1 June 1918), p. 3; Irish Independent (13 June 1918), p. 4; Derry Journal (20 June 1918); Derry Journal (26 June 1918), p. 2; Irish Independent (24 June 1918), p. 2; Irish Independent (4 July 1918), p. 4. 29  Irish News (21 June 1918), p. 3; Derry Journal (26 June 1918), p. 2. 30  Belfast Telegraph (11 June 1918), p. 3; Irish News (21 June 1918), p. 3. 31  Irish News (12 July 1918), p. 2. 32  Derry Journal (28 October 1918), p. 3; Derry Journal (6 November 1918), p. 3. 33  R. Barrington, Health, Medicine and Politics in Ireland, 1900–1970 (Dublin: Institute of Public Administration, 1987), p. 81. 34  H. P. Smyth, ‘Kathleen Lynn, M.D., F.R.C.S.I. (1874–1955)’, Dublin Historical Record, 30 (1977), 51–56 on p. 53. 35  M. Laffan, The Partition of Ireland 1911–25 (Dundalk: Dundalgan Press, 1983), pp. 58–9. 36  Belfast News-Letter (11 June 1918), p. 3; Northern Whig (21 June 1918), p. 2; County Down Spectator (29 June 1918), p. 3. 37  J. Winter, ‘The impact of the First World War on civilian health in Britain’, Economic History Review, 30:3 (August 1977), 487–503, 488. 38  C. Byerly, Fever of War: The Influenza Epidemic in the U. S. Army during World War One (New York and London: New York University Press, 2005), p. 8. 39  Donegal Vindicator (8 November 1918) p. 2; Dromore Leader (16 November 1918), p. 2. 40  C. Graves, Invasion by Virus: Can It Happen Again? (Icon: London, 1969), p. 7. 41  S. Tomkins, ‘Britain and the influenza epidemic 1918–1919’ (Ph.D. dissertation, University of Cambridge, 1989), p. 32. 42  N. Johnson, Britain and the 1918–19 Influenza Pandemic: A Dark Epilogue (London: Routledge, 2006), p. 163.

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The war and influenza 43  Belfast News-Letter (28 May 1918), p. 4; Irish Times (31 May 1918), p. 2; Westmeath Examiner (1 June 1918), p. 15. 44  Belfast News-Letter (19 June 1918), p. 47. 45  Irish Times (3 July 1918), p. 2; Irish Times (4 July 1918), p. 2; Irish Times (5 July 1918), p. 2; Irish Times (6 July 1918), p. 2; (8 July 1918), p. 6. 46  Portadown Express (28 June 1918), p. 3. 47  County Down Spectator (29 June 1918), p. 3. 48  Belfast News-Letter (30 October 1918), p. 6; Ulster Guardian (2 November 1918), p. 2. 49  Belfast News-Letter (23 October 1918), p. 6; Armagh Guardian (1 November 1918), p. 2; Belfast News-Letter (2 November 1918), p. 6. 50  Scotsman (2 July 1918), p. 4; Scotsman (3 July 1918), p. 3; Scotsman (8 July 1918), p. 4; Scotsman (9 July 1918), p. 3; Scotsman (10 July 1918), p. 3. 51  Johnson, Britain and the 1918–19 Influenza Pandemic, p. 163. 52  D. Blakely, Mass Mediated Disease: A Case Study Analysis of Three Flu Pandemics and Public Health Policy (Oxford: Lexington Books, 2006), pp. 23–4, p. 56. 53  Marsh, ‘Effect of the 1918–19 influenza pandemic on Ulster’, p. 245. 54  P. Alcabes, Dread: How Fear and Fantasy Have Fuelled Epidemics from the Black Death to Avian Flu (New York: Public Affairs, 2009), p. 112. 55  A. Crosby, America‘s Forgotten Pandemic: The Influenza of 1918 (Cambridge: Cambridge University Press, 2003). 56  H. Phillips and D. Killingray, ‘Introduction’, in H. Phillips and D. Killingray (eds), Spanish Influenza Pandemic of 1918–1919: New Perspectives (London: Routledge, 2003), pp. 13–14; Johnson, Britain and the 1918–19 Influenza Pandemic, pp. 179–80. 57  Phillips and Killingray, ‘Introduction’, p. 11. 58  D. Killingray, ‘The influenza pandemic of 1918–1919 in the British Caribbean’, Social History of Medicine, 7:1 (April 1994), 59–87, 66–7. 59  J. Hume, ‘The “forgotten” 1918 influenza epidemic and press portrayal of public anxiety’, Journalism and Mass Communication Quarterly, 77:4 (December 2000), 898– 915, 910. 60  Irish Independent (2 December 1918), p. 3. 61  J. M. Elyer, Sir Arthur Newsholme and State Medicine, 1885–1935 (Cambridge: Cambridge University Press, 1997), pp. 268–9. 62  Forty-Seventh Annual Report of the Local Government Board, pp. xxxvii–xxxviii. 63  Marsh, ‘Effect of the 1918–19 influenza pandemic on Ulster’, pp. 336–7. 64  Kew, WO 35/179/4, ‘Historical Records: Calls for Historical Review’, p. 2. 65  Tomkins, ‘Britain and the influenza epidemic 1918–1919’, pp. 98–9. 66  PRONI, BG/27/A/50, ‘Strabane Union Minute Book: Strabane Board of Guardians Meetings’, 27 September 1918, 8 October 1918 and 12 November 1918; Belfast-Newsletter (6 November 1918), p. 5; Derry People (9 November 1918), p. 3. 67  Derry People (23 November 1918), p. 1. 68  PRONI, BG/21/A/34, ‘Londonderry Union Minute Book: Londonderry Board of Guardians Meeting’, 15 March 1919; PRONI, BG27/A/50, ‘Strabane Union Minute Book: Strabane Board of Guardians Meetings’, 25 February 1919 and 13 May 1919. 69  PRONI, BG/26/A/85, ‘Omagh Union Minute Book: Board of Guardian Meeting’, 7 December 1918, 14 December 1918 and 11 January 1919. 70  PRONI, BG/12/A/82, ‘Downpatrick Union Minute Book: Downpatrick Board of Guardians Meeting’, 27 April 1918 and 9 November 1918. 71  Marsh, ‘Effect of the 1918–19 Influenza Pandemic on Ulster’, p. 276.

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Health and disease on the domestic front 72  Forty-Seventh Annual Report of the Local Government Board, pp. xxvi, xxvii and xxxvii; Barrington, Health, Medicine and Politics in Ireland, p. 73. 73  Byerly, Fever of War, pp. 144–5. 74  PRONI, BG21/A/33, ‘Londonderry Union Minute Book: Londonderry Board of Guardians Meetings’, 16 November 1918 and 23 November 1918. 75  PRONI, BG/3/A/49, ‘Ballycastle Union Minute Book: Ballycastle Board of Guardians Meetings’, 3 December 1918. 76  D. W. Macnamara, ‘Memories of 1918 and “the ‘flu” ’, Journal of the Irish Medical Association, 35 (July–December 1954), 304–9, 306. 77  Foley, Last Irish Plague, pp. 91–2. 78  Ministry of Health, Report on the Pandemic of Influenza, p. 54.

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3

Food, the Emergency and the lower-class Irish body, c.1939–45 Bryce Evans

Shortly after Britain’s declaration of war on Germany on 3 September 1939, the Irish government passed the Emergency Powers Act. This Act enabled the government to maintain its policy of neutrality by exercising an unprecedented level of centralised state control over the body politic, economy and society in independent Ireland.1 As in other states in wartime, the government assumed extraordinary power over the very bodies of the general public, not least because the national food supply assumed paramount importance. To highlight the wartime importance of dietary concerns, this chapter addresses public health issues in neutral Ireland during the Emergency through the prism of diet and the lower-class Irish body. For many commentators in the United Kingdom, Irish neutrality was greedy; the neutral Irish body, by implication, seemed unjustifiably plumper than its war-hardened equivalent. While Winston Churchill’s renowned broadsides against his counterpart Éamon de Valera adopted this line, this sentiment was most savagely articulated by Irish poet Louis MacNeice who, looking west from his London home, imagined the far-off Battle of the Atlantic and closer, around Irish shores, ‘the mackerel … fat – on the flesh of your kin’.2 The message was clear: people in neutral Ireland were being spared the horrors of war while simultaneously consuming the shipped supplies for which British sailors were dying to secure. At worst, in consuming fish fed on corpses the neutral Irish body was rendered cannibalistic. This image bled into a hegemonic British wartime narrative in which Ireland – imagined as a land of milk and honey thanks to its blissful neutrality – was juxtaposed with the slimbodied people of austerity Blighty. These examples demonstrate how food issues were propagandised during wartime. A dichotomous narrative of, on the one hand, absence and, on the other, abundance often justified the fight. The enemy was portrayed as

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a rapacious fatso, whose greed forces starvation on his victims; a different creature altogether to the virtuous home front patriot who practised frugality and consumptive sacrifice. Neutrals, in their content complacency, could be depicted as complicit in the enemy’s greed. Never was this wartime rhetoric of absence versus abundance thrown into sharper relief than during the Second World War, a conflict in which hunger was regularly used as a weapon of war and in which over 20 million people died of starvation and its related diseases: a number exceeding the 19.5 million military deaths.3 Back on the western side of the Irish Sea, in independent Ireland, government propaganda conformed to type. In neutral Ireland, the governmentendorsed narrative of ‘moral neutrality’ (as Donal O’Drisceoil terms it) painted Éire as a frugal nation righteously shunning the covetous lure of imperialistic war.4 Ireland was, in the words of one influential political commentator, right to stay out of ‘a competition in atrocity in which victory goes to the competitor who kills and destroys most’.5 Neutral Ireland, by implication of its state propaganda, was certainly not greedy when it came to food. Quite the opposite, in fact. This chapter argues that in the official Irish narrative, virtuous and anti-materialistic Éire was actually struggling to feed its people under the corpulent weight of Churchillian economic pressure. In this battle, as the Irish Minister for Agriculture James Ryan confirmed, Ireland ‘had no army in the fighting line to feed’ but nonetheless had to nourish ‘the old, the infirm, the children, the masses’.6 Instead of the front-line soldier, the Irish ploughman, hallowed in post-independence culture as the embodiment of honest Christian toil, would be Ireland’s shock troop. Rugged and fit, his production of food would sustain the lean Irish body and, in doing so, defy global plutocracy and its avaricious appetite for destruction. These two official narratives, one British and one Irish, are so divergent that both cannot be true. This chapter explains why, and outlines the reality of Irish experience in the Second World War. Due to the global and national food supply situation, the lower-class Irish body became under-nourished. In fact, in defiance of both the dominant British and Irish narratives, the typical labouring/poor Irish person was neither, as British propaganda suggested, tubby; nor, as Irish propaganda urged, svelte. Rather, as this chapter outlines, thanks to wartime conditions aspects of public health among the working class in neutral Ireland remained poor and, in tandem, nutritional standards declined markedly between 1939 and 1945. Ireland may have been neutral, but the impact of wartime on the bodies of the Irish was telling. This chapter builds on the renewed interest within the disciplines of history and sociology in ‘body work’ that has focused on the working class in this period.7 These newer works are indebted to an established literature on the body, work and power. Prominent examples include the works of Michel Foucault and Pierre Bourdieu, while Carol Wolkowitz has explored the same theme from a gendered perspective.8 In turn, this analysis of nutritional issues

Food, the Emergency, the lower-class Irish body

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in Emergency-period Ireland builds upon a key theme set out in earlier chapters: the problematisation of Irish health on the domestic front during international conflicts; even those in which Ireland refused to involve itself. In the first section, this chapter maintains that Anglo-Irish economic and political relations were a primary cause of nutritional problems in Ireland, compounded by deficiencies in Irish domestic policy. The second section fortifies this argument through an analysis of the numerous health conditions that arose nationally during the Emergency. Food, health and Anglo-Irish relations Food-related anxieties in Ireland were not unique to the Emergency period. Perceptions of the ‘Irish body’ had traditionally been constructed around food (or its absence) and the Irish diet. After the Great Famine (1845–51) periodic panics arose about the nutritional well-being of the Irish body, particularly those of working or poor people. First World War-period debates on the likelihood of a second Famine due to international trade disruption (discussed elsewhere by John Borgonovo and Ian Miller) resonate here.9 Amid the economic problems and political conservatism following the War of Independence and Civil War, panic about the absence of food recurred. The poor harvests of 1923 and 1924 even led the Manchester Guardian to follow Soviet daily Pravda’s lead in carrying pictures of emaciated children in Co. Galway and warning that one-quarter of a million people faced starvation in Ireland.10 Nonetheless, Emergency-period food anxieties took on particular contours. Before exploring the negative effects of the war on the lower-class Irish body, it is first necessary to explore the causes. These lay in Anglo-Irish trade relations. The British supply squeeze on neutral Ireland, in place from 1941 onwards, would be the single greatest factor that impacted negatively on public health in the country between 1939 and 1945. However, the story of food and the wartime Irish body is not all about British economic perfidy, and it is necessary to outline several systemic failures in the Irish government’s approach to the food situation. In the first instance, Ireland’s failure to establish a merchant marine in the interwar period compounded the country’s wartime food supply problems. As early as the Munich Crisis of September 1938 (the settlement that permitted Nazi Germany’s annexation of portions of Czechoslovakia), the British Board of Trade made it clear that, in the event of war, a British maritime blockade would force all neutral shipping into British hands. The Irish government, however, was enjoying the upsurge in relations following the Anglo-Irish trade settlement of April that year and did not move to establish their own merchant fleet.11 To put this failure in context, even Switzerland – landlocked and neutral – secured Basel as a ‘Swiss seaport’ prior to the outbreak of war in order to better secure food and fuel supplies.12 This major oversight ensured that Irish Shipping Ltd, the state-run company which

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the government established in 1941, was simply unable to secure enough tonnage to meet the nation’s food supply needs.13 Second, the Irish Department of Supplies’ attempts to ‘lay in’ stocks of food and medicines at the outbreak of war were met with the non-cooperation of a host of native firms. This was because the Department refused to guarantee against any losses which might be incurred by the private companies in doing so.14 As the war progressed, the Department of Supplies nominated firms as ‘central importing agents’ for certain goods, a move again met by resistance by businesses due to the inherent risk involved in the bulk importing of foodstuffs. As a result, senior Irish civil servants cried ‘unpatriotic’ while business leaders responded with accusations of ‘heavy-handed’ state interventionism. Some of these differences were gradually hammered out but, once again, belatedly. In some cases, the Department and food importers remained at loggerheads. For example, vitamin D supplies in the state remained inadequate for much of the war chiefly due to an unresolved conflict between the Department of Supplies and Irish Oil and Cake Supplies, the country’s largest importer of the vitamin.15 Third, rationing was implemented too late in neutral Ireland. Although certain goods were rationed individually and most were subject to price control orders, neutral Ireland did not adopt a full rationing system until May 1942.16 The Department of Supplies instead relied on ‘voluntary methods of rationing’, imploring housewives to avoid using scarce foodstuffs such as white flour. Ultimately, the Irish state placed too much faith in the public’s adherence to its price orders and voluntary movements such as ‘NBBL’ (the No Bread for Breakfast League).17 Due to a lack of a coherent and comprehensive rationing programme, the black market boomed. Campaigning voluntary societies such as the Irish Housewives Association pressured the government to introduce rationing and the Department of Supplies eventually did so, albeit without acknowledging the popular pressure that had necessitated its actions. All the while, the demand for scarce goods such as tea and white flour left Irish consumers at the mercy of racketeers who charged extortionate black market prices. Meanwhile, the Irish government belatedly realised that the smuggling trade across the Irish border (which thrived on disparities in the rationing system of Northern Ireland and the rather haphazard model south of the border) was aggravating food poverty and malnutrition in the neutral state.18 Following the outbreak of war, separate rationing schemes were introduced on either side of the border, leading to demand for items more readily available in one territory than the other. Butter, bacon, eggs, sausages, ham, beef and jellies were lapped up by hungry northerners. In the opposite direction flowed soap, wireless batteries, candles, white bread, paraffin oil, sugar, cycle tyres, contraceptives and, most commonly, tea and flour. Ireland’s policymakers were, though, at the mercy of geopolitical conditions beyond their immediate control. The fall of France in June 1940

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disrupted continental trade and precipitated the hardening of British attitudes to Ireland. This was because, as outlined above, Churchill viewed Irish neutrality as not only self-serving but greedy. By the end of 1940, it looked as if Éire could not survive the war for much longer as a neutral country. The washing up of deformed and bloated bodies on the west coast of Ireland – casualties of the Battle of the Atlantic – was, for Churchill, evidence that the character of Irish neutrality was mercenary rather than virtuous.19 With one eye trained on control of the Irish ports and the other on the British-shipped supplies Ireland was eating up, he wrought revenge by subjecting the Irish people to an agonising supply squeeze.20 In an attempt to coerce Ireland onto the Allied side, Churchill oversaw the throttling of the Irish economy throughout the pivotal year of 1941. De Valera’s Ireland, still without its own merchant navy and perilously reliant on British supplies, was now subjected to the full force of British economic warfare. The year 1941 would prove to be Ireland’s wartime annus horribilis. Attempting to deliver a death blow to the Irish agricultural economy, the British Board of Trade cut the vital annual supply of agricultural fertilisers to Ireland from 100,000 tons to nothing.21 Similarly, the British supply of feeding stuffs was slashed from 6 million tons to zero.22 The transport of food and medicines was seriously compromised by Britain cutting off coal and petrol supplies. With bellies rumbling and the centenary of Ireland’s Great Hunger approaching, there were reports of the Phoenix Park deer and even Dublin Zoo animals going missing.23 Dublin prostitutes, according to contemporary accounts, asked for payment not in cash but in sought-after commodities like soap and tea.24 In terms of public health, the medium-term impacts of this uncomfortable squeeze on food supplies would prove significant. As wheat production waned, the Irish state desperately introduced the 100 per cent black loaf. This, in turn, inhibited calcium absorption, leading to a massive increase in childhood rickets. Phytic acid in 100 per cent whole grains inhibits calcium absorption (a problem discussed in more depth below).25 It was claimed in the Dáil that ‘the poor are like hunted rats looking for bread’.26 To top it all, German bombs rained down, Dublin Castle was ravaged by fire and, most ominously, Ireland suffered a serious foot-and-mouth outbreak.27 This latest arrival was a devastating blow for a predominately agricultural economy and it came in the middle of everyday hardships such as a decline in purchasing power which accompanied the black market boom and a nationwide wage freeze. Meanwhile, Irish workers experienced a fall in wages in real terms and a steep rise in the cost of living.28 Localised famine soon became a realistic fear. These circumstances meant that public health rapidly declined. To be sure, the Irish body did not undergo uniform hardship. Food supply in country areas was compromised by transport shortages, but people in certain areas were able to live well off the fat of the land.29 Furthermore, Anglo-Irish trade wars could actually prove favourable to communities straddling the Irish

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land border. Residents of border counties were able to supplement their diet by hopping over the border and buying up food supplies from the neighbouring demesne where white bread and tea were more readily available. In Counties Fermanagh, Donegal, Monaghan and Leitrim there were several examples of young women feigning pregnancy in order to smuggle white bread back over the border as well as young men cross-dressing to avoid customs detection.30 The Irish government scored one notable success in relation to food supply. In March 1942, in an effort to preserve wheat supplies and ensure that the poor could purchase bread, it imposed restrictions on the malting of barley and banned the export of beer altogether. After the British Army complained to Whitehall of unrest caused by a sudden and ‘acute’ beer shortage in Belfast, a hasty agreement was drawn up between senior British and Irish civil servants. Britain would exchange badly needed stocks of wheat in exchange for Guinness. Slowly but surely, though, this pattern of barter repeated itself. Faced with a ballooning and dry-tongued garrison of American and British troops in Northern Ireland in the long run-up to D-Day in June 1944, the British and Americans periodically agreed to release stocks of wheat, coal, fertilisers and agricultural machinery – vital components of food production and consequently public health – in exchange for Guinness.31 Neither did British obstinacy on supplies override all public health concerns. Most trade deals, if not achieved through barter, were carried out in the mean spirit of self-interest. Occasionally, self-interest and mutual interest coincided. For example, the smallpox vaccine for the island of Ireland was produced in Dublin, with one third of it being sent north of the border annually. In 1942, the manufacturer complained of a shortage of capillary glass tubes, an item unobtainable in Éire. In this case, the British authorities were more than willing to supply Ireland with the required glass tubing so that manufacture could continue in Dublin. Why? A serious smallpox outbreak had occurred in Glasgow that year and, due to the volume of people moving between Scotland and Northern Ireland, fears arose that a similar outbreak might occur in Belfast.32 In this case, then, it suited Britain to temporarily relax the trade squeeze. Overall, Ireland’s national food supply situation clearly deteriorated between 1939 and 1945. The evidence cited above suggests that the reasons for this were largely geopolitical. Stormy British–Irish trade relations impelled the Irish government to implement emergency food measures such as introducing the black loaf and to resort to rationings. The absence of an established Irish merchant marine, and the presence of a porous land border, aggravated this situation. The remainder of this chapter demonstrates that this adverse situation impacted profoundly on the health of the Irish lower classes, further supporting the view that stereotypical images of the overfed or svelte neutral Irish body need to be discarded.

Food, the Emergency, the lower-class Irish body

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Public health impacts How did broader geopolitical scenarios impact on the health of the Irish poor? What diseases did the lower-class Irish body become susceptible to? And how effectively did the Irish government respond to mounting health concerns? This latter question can be answered easily. Although a number of local government reforms took place in Ireland before 1939, the majority of Acts designed to improve national health were passed only after the war. These included the Mental Treatment Act and Tuberculosis Act (both 1945), the Ministers and Secretaries Act (1946) and the Health Act (1947).33 A number of public health measures were in fact passed under the Emergency Powers Act between 1939 and 1945. These included Emergency Powers Order (number 46) which enabled the Minister of Local Government and Public Health to detain and isolate anyone considered a threat to public health; and the Public Health (Infectious Diseases) regulations of 1941 which, along with several subsequent Emergency Powers Orders, made the majority of infectious diseases compulsorily notifiable.34 In terms of disease and death, these Emergency-period measures registered some notable successes. Although powers to detain and isolate sick people grossly infringed personal liberty, they did result in a steady decline in the number of deaths caused by infectious diseases from 1941 onwards.35 Similarly, average annual maternal mortality rates actually declined in this period, in part due to the availability of sulphonamides provided under the infectious diseases regulations of 1941. This same legislation authorised the inspection of midwives in instances where puerperal sepsis had been detected in a patient during or after childbirth. Midwives had their noses and throats swabbed to prevent further infection.36 The average number of people covered by the National Health Insurance Acts also rose steadily from 1932 onwards, peaking at 417,000 in 1939. These figures steadily declined over the course of the war years, meaning that, overall, less people were insured against ill health as wartime privations continued. However, free (if much limited and means-tested) healthcare was available to approximately one-third of the population during the early 1940s.37 Nonetheless, the overall picture of national health that emerges from the Emergency is less reassuring, particularly when the epidemiological spread of particular infectious diseases is taken into account. The above gains were eclipsed by independent Ireland’s generally poor public health record during the conflict. The poverty of this record was linked in almost every case to the problems in the supply situation outlined above. For instance, although maternal mortality rates dropped, infant mortality remained comparatively high in neutral Ireland. Infant deaths peaked at 83 per 1,000 in 1943. These figures compared to just 46 per 1,000 in England and Wales, 67 in Northern Ireland, and 65 in Scotland in the same year.38 These relatively high figures were closely

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linked to the effects of malnutrition, which contemporary reports from the Department of Local Government and Public Health partially linked to both the poor food supply situation and the systemic failures in managing it. One key problem was that in combating infant mortality, the Irish state was overly reliant on voluntary welfare schemes. Dinners for expectant and nursing mothers in Dublin were given out by Archbishop John Charles McQuaid’s Catholic Social Service Conference (CSSC) and numbered 250,000 during 1944 alone.39 In contrast to the free meals provided by the state through feeding centres established in Dublin and its environs, which often consisted of just milk or cocoa with bread and butter or jam, the CSSC provided mothers and young children with hot food made from fresh vegetables.40 But, as a post-war Department of Health retrospective put it, infant mortality in Ireland nonetheless remained ‘abnormally high’ during the war years.41 While the Department of Local Government and Public Health could blame the rise on childhood diphtheria between 1939 and 1945 on ‘parental apathy’,42 it was less easy to explain away the upsurge in other illnesses linked to poor nutrition which often had serious implications for children, such as diarrhoea. As the Department admitted, there was ‘severe incidence’ of diarrhoea during the wartime period (at a higher level than in the interwar period), so much so that a special hospital was set up in Dublin to accommodate infant cases of gastroenteritis. As well as establishing Saint Clare’s hospital in 1944, under the 1943 amendments to the 1941 Infectious Diseases legislation, the Department made it compulsory to report cases of childhood diarrhoea.43 Public health among Irish teenagers and young people was scarred by the most lamented disease of the period: tuberculosis. As with other diseases that thrived at the time, a lack of adequate nutrition compounded Ireland’s tuberculosis problem by increasing susceptibility (as also discussed in Chapter 4 in this volume). Tuberculosis was most common in young people and independent Ireland experienced a marked upward trend in mortality between 1939 and 1943. The Department of Local Government and Public Health attributed a decline in 1944 to a mild winter while acknowledging that a significant factor underlying the still high mortality statistics was the inability to provide extra nourishment for sufferers. This was, once again, due to supply shortages, as the Department indicated in its 1944 report.44 The Department of Supplies, it intimated, bore ultimate responsibility for these. Tuberculosis in the period is the subject of an extensive historiography which centres primarily on the clash between church and state actors that anticipated the post-war political crisis surrounding the Mother and Child Scheme.45 By 1943 there were already disputes between the Department of Local Government and Public Health, whose steps to eradicate the disease fell foul of Archbishop McQuaid, who wanted the anti-tuberculosis campaign to be run by the Irish Red Cross.46 Tensions over how to deal with Ireland’s tuberculosis problem resurfaced after the implementation of the Public Health

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Bill, introduced in the Irish parliament on 15 November 1945. This typically illiberal piece of Emergency legislation contained provisions for the confinement of infectious diseases, proposed isolating sufferers from the public sphere (streets, hotels, shops); established the right of the state to inspect citizens against their will; and imposed compulsory long-term hospitalisation.47 Defeated by an eclectic opposition of Fine Gael, members of the medical profession and tuberculosis patients, it was – said future Minister for Health Noel Browne – a ‘draconian and jackboot’ act reflective of the ‘cavalier indifference’ towards tuberculosis sufferers at the time. It was, nonetheless, symptomatic of the extraordinary regulation and ordering of the bodies of the sick in Ireland between 1939 and 1945. Throughout these years, tuberculosis incidence, like infant mortality, remained ‘heavier in this country than in others where health services are in a comparable state of development’.48 If the youthful Irish body was disproportionately subject to the physical misery of tuberculosis, young Irish people faced other health obstacles reflective of the heavy economic price of neutrality. Due to the British trade squeeze, Ireland faced a lack of soap. Consequently, lice infestation became a problem, particularly for young emigrants.49 Several leading doctors established delousing centres in Dublin where they shaved off all of the body hair of male emigrants and doused them all over in blue disinfectant. But if the ‘Health Embarkation Scheme’ was an example of vigorous state action carried out upon Irish bodies in the period, the management of venereal disease was not. Venereal disease treatment was ‘handicapped’ by ‘difficulties in case finding and treatment’ and the lack of uniformity in its application across the country. In its survey of health provision in Ireland during the Emergency, published in 1947, the Department of Health admitted that measures to combat venereal disease had been ‘loose and haphazard’.50 Perhaps most worryingly, diseases that had mostly disappeared from Ireland started to reappear, afflicting all age groups. Another consequence of poor sanitation seemingly linked to the national supply crisis was the reappearance of typhus, a disease which underwent an unexpected increase in incidence between 1939 and 1945. In popular memory, typhus was most associated with the Great Famine; its incidence in Irish Famine-era emigrants earning it the sobriquet ‘the Irish disease’. Despite its virtual eradication from Ireland in the previous decade, outbreaks of typhus were reported in poor areas in western regions of Ireland in 1943 in Clare, Galway and Leitrim. In Clare, in a cluster of houses described as ‘wretched hovels’, there were thirteen cases characterised by mental torpor, malnutrition and victims ‘infested with vermin’.51 It was no coincidence that the disease struck in the remotest parts of the western seaboard. These areas experienced the worst of food supply shortages and dislocation during the period.52 Food scarcity in these areas was vividly illustrated by León Ó Broin, one of seven regional commissioners appointed by the Department of Supplies in July 1940 as a contingency against invasion. Hurried

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to remote Irish-speaking area of Mayo by an aide, Ó Broin was confronted by emaciated people moving down the hills towards his car, carrying sacks which they begged to be filled with flour and stating that they feared a recurrence of the Great Famine.53 The Department of Local Government and Public Health blamed the recurrence of typhus on long-term overcrowding and poverty, but perhaps short-term factors such as a lack of adequate food supplies in outlying areas and the supply dearth in pesticides and insecticides were also significant. Once again, these harsh economic conditions were intrinsically linked to the supply situation, which was specific to the wartime period. In 1941, for example, the first case of typhus in Galway since 1907 occurred.54 In consequence of the ongoing British trade squeeze, supplies of DDT insecticide that might have helped to eliminate the disease remained unavailable until 1945. Similarly, ‘Red Squills’, the most effective rat poison at the time, was produced in the East Indies and was a casualty of wartime trade disruption despite being readily available in interwar Ireland.55 Amid the recurrence of famine diseases like typhus, the lack of rat poison in Ireland led to fears of an even older public health concern: bubonic plague. A nervous Irish health administration ordered rats to be captured on ships in Dublin and Cork, and inspected to determine if they carried plague.56 Although the results were negative, the very fear of plague illustrates the anxieties that arose around the supply situation and the lack of poisons and insecticides was also having an adverse impact on Irish food production, further worsening food poverty and malnutrition. The link between infectious diseases and poor sanitation soon led to scapegoating. The Department of Local Government and Public Health partially blamed the typhus outbreak on ‘itinerants’ in Counties Leitrim, Roscommon and Donegal. Its 1943–44 report went as far as to blame ‘itinerant tinkers’ as the main cause of the spread of the disease.57 The Department’s calls for ‘more power by legislation to ensure that the standard of cleanliness among that class will be improved’ were met by local action, with travellers subject to internment by certain local authorities during periods such as the foot-and-mouth outbreak of 1941.58 Another symptom of poor standards of sanitation – typhoid – underwent an increase, too, most notably in Kerry. The majority of typhoid outbreaks were due to poor sanitary standards in the serving of food: thirtyfour cases in Dublin alone were traced to the restaurant car of a train. The Great Northern Railway Company, which carried out its own sanitary inspections of railway buffet cars and railway hotels in 1942, noted ‘dirty conditions’ in several instances. The company’s inspectors also thought it worth noting the high number of ‘aliens’ (foreign nationals) involved in food production.59 Typhoid outbreaks were also witnessed in mental hospitals, where they were difficult to eradicate, as many patients ignored instructions on hygienic eating.60 Another noticeable consequence of wartime privations on the lower-class Irish body was surely the increase in rickets. A consequence of a lack of

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calcium in the diet, it is plausible that this physical deformity was directly linked to, and almost certainly worsened by, both the British trade squeeze and the domestic shortcomings in administering food supplies and public health during the Emergency. Wartime bread quality was a major contributing factor. In 1944 the government undertook a nationwide survey to examine the relationship between nutrition and physical health. Research undertaken into dietary standards across social class groups in Dublin, undertaken in early 1946, noted a calcium deficiency seemingly caused by the popularly detested ‘black loaf’. This 100 per cent wholegrain staple had been introduced in February 1942 due to the chronic wheat shortage in the country.61 Inhibiting the absorption of phytic acid, the ‘black loaf’ accounted for many cases of rickets in poor inner-city families who, it was feared, mainly subsisted on bread and tea.62 The survey recommended that working-class families increase their consumption of vitamin C by purchasing cheese and milk, but acknowledged the lack of purchasing power due to wartime inflation militating against such measures. A clinical survey of children which formed part of the survey revealed that height and weight disparities between the classes was more pronounced in urban areas and was likely to persist unless far-reaching social change occurred.63 In the lowest income groups surveyed in Dublin, calcium intake reached as low as 51 per cent of requirements specified by contemporary nutritional experts. In more affluent areas, intake comfortably reached 100 per cent. This problem had presumably been worse during wartime as from June 1946 onwards, when the survey was being conducted, acid calcium phosphate had started to be reincorporated into bakers’ flour. By 1947, when the survey concluded its research, the extraction rate in bread had been lowered to 85 per cent.64 During the years of the ‘black loaf’, which was subsidised in price by the Department of Supplies in order to encourage its consumption, calcium intake was lower. Overall, according to the survey, the urban intake of protein and calories were ‘more or less satisfactorily met’ by 1946, although its authors conceded that numerous families were ‘hidden in the results’ whose intake was seriously deficient. With categories of urban class divided under ‘slum’, ‘artisan’ and ‘middle class’, the report reiterated the fact that most of the lowest income families at the time were subsisting on a staple diet of ‘bread and spread’ rather than ‘cooked’ meals. With people struggling to digest the ‘black loaf’ and some swearing off bread as a result, this nutritional situation inevitably left such people more vulnerable to infectious diseases, claimed the report.65 However, the ‘black loaf’ does not deserve all the bad press for wartime calcium deficiency. Calcium intake was also compromised by the poor milk supply in Ireland at the time. In Ireland’s urban centres bigger, poorer families not only ate less well, the intake of milk in such families – vital for infants and expectant mothers – was well below international recommendations.66 The pre-independence Committee of Inquiry into the Dublin Milk Supply (undertaken in 1918 and reported in 1919) detailed the inadequacy of supply and

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proposed the establishment of a wholesale milk distribution agency to ensure adequate supply. No effective action followed this report, partly due to the War of Independence but the quality of milk supply in Ireland was regulated through the Milk and Dairies Act 1935.67 Between 1939 and 1945, however, these regulations were allowed to slip. Seven separate Emergency Powers Orders related to milk, but these were designed to ensure adequate distribution. Struggling to cope with wartime shortages in petrol and other key supplies, the government was more concerned with ensuring supply than quality. Accordingly, regulations on quality were relaxed to ensure quantity. Creameries without adequate pasteurisation plants were allowed to sell in order to prevent shortages and prices were controlled.68 Past milk was allowed to circulate, subject to regulation by plate test. Pre-war regulations, which dictated that milk with over 500,000 bacteria per cubic centimetre should not be pasteurised and sold, were relaxed. Similarly, traders selling pasteurised milk containing over 100,000 bacteria per cubic centimetre (the limit) were not prosecuted.69 Due to wartime supply difficulties, the quality of Irish milk seriously deteriorated. Clinical examination of milk at the time could only detect bovine tuberculosis when at an advanced stage. The tuberculin used for tests (also in short supply) was neither standardised nor readily available. Bovine tuberculosis – possibly the greatest threat to public health through milk – was exacerbated by supply problems, with herds suffering undernourishment, contagious abortion, bovine mastitis and poor veterinary care.70 Due to demand outstripping supply, especially in the winter months, milk consumption remained undesirably low. Transport problems caused by the British trade squeeze ‘retarded’ pre-war progress in milk supply.71 And yet the greatest factor limiting adequate consumption of milk, and thus calcium, was its price. This was a domestic failing. Periodic price controls were placed on milk, but these largely went ignored by the public.72 Quite simply, comprehensive coupon-based rationing was implemented too late in Ireland; so late that the culture of profiteering and resort to black market prices was well established by mid 1942 when rationing finally arrived. The relaxation in regulation led to frequent public complaints that milk was dirty and soured prematurely. Overall milk consumption fell as a result.73 Illustrative of the negative consequences of deregulation, as well as the state’s toothlessness in the face of industry selfishness, was a landmark 1945 trial concerning milk supply. A businessman who had supplied milk so contaminated that it had made hundreds of Dublin schoolchildren seriously ill successfully appealed against his conviction on the technicality that the relevant Act did not apply to the size of bottles he was peddling.74 Evidently, Dublin’s poor suffered under such conditions. A dietary survey of Ireland’s ‘congested districts’, conducted in the same survey, revealed that nutritional health was similarly poor in remote western areas. Confined to ‘rural slums’, or people resident on the poorest land in counties such as Mayo

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and Galway, researchers found that dietary trends were highly seasonal. Consumption of milk, meat, bread and potatoes was highest in the autumn, when most physical work was required. However, consumption of nearly all foodstuffs fell rapidly in the spring. Most families, as was the case in Dublin, were reported to be consuming tea, bread and butter as a high percentage of their main meal, leading the survey’s authors to criticise the monotony of the diet and the deficient intake of vegetables and fruit.75 Calcium intake was again flagged as a cause for concern, as it was in Ireland’s large and small towns.76 Once again, had such a survey been undertaken during the years of the worst supply shortages (1941–43), it is likely that the results would have been even more concerning. Poor nutrition was not, of course, universal. Farming families fared better nutritionally, with a higher intake of milk, eggs, potatoes and vegetables. The bigger the landholding, the better the diet, although farmworkers’ diets were reported to be ‘generally good’ and certainly superior to their urban working counterparts.77 Moreover, as wartime privations continued, the government recognised the need to improve nutrition among the lower echelons of the population for the good of public health. Allotments were provided at reduced rates for the unemployed and underemployed, with seeds, manure and tools provided free by the Department of Agriculture. Between 1940 and 1945, the Irish state allocated 100,000 allotments to those most in need of the fresh vegetables they provided.78 Despite these measures, public health in Ireland between 1939 and 1945 was generally poor. The price of neutrality was a heavy one indeed, with the lower-class Irish body displaying the effects of British economic warfare and domestic failures in the management of food supply. Although class differences dictated experience, in general the lowerclass Irish body bore the negative effects of black markets, black bread and infectious diseases. It was a reality far removed from the body image portrayed in either British or Irish state propaganda of the time. Conclusion The story of Ireland’s material survival during the Second World War has been long obscured by a rather abstract high political debate about the rights and wrongs of Irish neutrality.79 While diplomatic debates are integral to the history of Ireland during the Second World War, the story of food and the Irish body is revealing of the very real physical consequences of political dispute. Certainly, Ireland’s poor public health record at this time deserves to be cited more often in broader debates about how worthwhile Irish neutrality actually was, as well as arguments surrounding the record of the post-independence Irish state. This chapter has, though, for now, put those debates to one side in favour of debunking the myth of the Irish body as represented in British and Irish state propaganda of the period. The image of the contented, fleshy Irishman – living

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off the fat of the land while Europe burned – does not hold up to scrutiny. Neither does the Irish ideal of the healthy ploughman feeding a frugally minded population. Although Ireland was neutral, life bore all the hallmarks of a war economy. The noble ploughman’s toil was so hamstrung by state interventionism and supply shortages that most land was mined, not farmed, in a desperate attempt to grow more food. The Irish countryside witnessed camp labour, emigration and disease. Meanwhile, cross-border smugglers amended their bodies – cross-dressing and feigning pregnancy – in desperate attempts to procure more food. The point has been made many times, but bears repeating: all this was some way from the ‘sturdy children’ and ‘athletic youths’ which Ireland’s political leaders dreamed of. Notes   1  For the administrative changes wrought by this legislation, see M. E. Daly, The Buffer State: The Historical Roots of the Department of the Environment (Dublin: Institute of Public Administration, 1997), p. 249.   2  L. MacNeice, ‘Neutrality’, in E. Longley and M. Longley (eds), Louis MacNeice: Selected Poems (London: Faber and Faber, 2007).   3  L. Collingham, The Taste of War: World War Two and the Battle for Food (London: Penguin, 2011), p. 1.   4  See D. O’Drisceoil, Censorship in Ireland, 1939–1945: Neutrality, Politics and Society (Cork: Cork University Press, 1996).   5  A. O’Rahilly, cited in B. Evans, Ireland during the Second World War: Farewell to Plato’s Cave (Manchester: Manchester University Press, 2014), p. 10.   6  Irish Press (11 October 1939).   7  Two recent examples are J. Field, Working Men’s Bodies: Work Camps in Britain, 1880–1940 (Manchester: Manchester University Press, 2013) and I. ZweinigerBargielowska, Managing the Body: Beauty, Health and Fitness in Britain, 1880–1939 (Oxford: Oxford University Press, 2010).   8  M. Foucault, Discipline and Punish: The Birth of the Prison (New York: Vintage Books, 1979); P. Bourdieu, ‘Sport and social class’, in C. Mukerji and M. Schudson (eds), Popular Culture: Contemporary Perspectives on Cultural Studies (Berkeley, CA: University of California Press, 1991); C. Wolkowitz, ‘The working body as sign: historical snapshots’, in K. Backett-Milburn and L. McKie (eds), Constructing Gendered Bodies (Basingstoke: Palgrave Macmillan, 2001).   9  John Borgonovo, ‘Food preservation, agitation and agrarianism in Ireland, 1918’. Presentation delivered at Food and the First World War, Liverpool Hope University, 2 April 2014; I. Miller, Reforming Food in Post-Famine Ireland: Medicine, Science and Improvement, 1845–1922 (Manchester: Manchester University Press, 2014), pp. 173–96. 10  Manchester Guardian (2 February 1925). 11  Evans, Ireland during the Second World War, pp. 18–21. 12  National Archives (Kew) (hereafter Kew), Anthony Eden papers, FO/954/28A, R. A. Butler, ‘Memorandum: Ships under the Swiss Flag’, 11 April 1943. 13  See B. Peterson, Turn of the Tide: An Irish Maritime History (Dublin: Irish Shipping, 1962); B. Evans, ‘A semi-state archipelago without ships: Seán Lemass, economic policy and the absence of an Irish  mercantile marine’. www.historyhub.ie/lemass -marine. Accessed 12 June 2013, 30 December 2014.

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Food, the Emergency, the lower-class Irish body 14  National Archives of Ireland (hereafter NAI), IND/HER/3/C1–C2, ‘Historical Survey’, undated. 15  Ibid., p. 88. 16  Ibid., pp. 32–5. 17  T. Gray, The Lost Years: The Emergency in Ireland, 1939–45 (London: Little Brown, 1988), p. 185. 18  B. Evans, ‘A pleasant little game of money-making: Ireland and the new smuggling’, Eire-Ireland, 49:1 (spring/summer 2014), 44–68, 25. 19  Kew, 67/8/13, ‘Fred Leathers to Winston Churchill’, 12 August 1940. 20  See also R. Fisk, In Time of War: Ireland, Ulster and the Price of Neutrality 1939–45 (Dublin: Gill & Macmillan, 1996), pp. 100–24; P. Rigney, Trains, Coal and Turf: Transport in Emergency Ireland (Dublin: Irish Academic Press, 2010), pp. 82–90. 21  NAI, ‘Historical Survey’, p. 21. 22  Ibid., p. 601. 23  Gray, Lost Years, p. 156. 24  W. Mahon-Smith, I Did Penal Servitude (Dublin: Metropolitan Publishing Company, 1946), p. 14. 25  National Nutrition Survey Report Part One (Dublin, 1948), p. 12. 26  R. Mulcahy, cited in C. Wills, That Neutral Island: A Cultural History of Ireland during the Second World War (London: Faber and Faber, 2007), p. 241. 27  Dáil Debates (1 July 1941), vol. 84, col. 551. 28  Evans, Ireland during the Second World War, p. 8. 29  Ibid., pp. 75–86. 30  Ibid., pp. 91–113. 31  Ibid., pp. 25–6. 32  NAI, ‘Historical Survey’, p. 501. 33  Department of Health, Health Progress 1947–1953 (Dublin, 1953). 34  Report of the Department of Local Government and Public Health 1941–1942 (Dublin, 1942), p. 37. 35  Ibid., p. 20. 36  Ibid., p. 31. 37  Statistical Abstracts (Dublin), 1932–1945. 38  Report of the Department of Local Government and Public Health 1943–1944, p. 45. For an in-depth examination, see L. Earner-Byrne, Mother and Child: Maternity and Child Welfare in Dublin, 1920s–1960s (Manchester: Manchester University Press, 2007). 39  Dublin Diocesan Archives (hereafter DDA), McQuaid papers, AB8/B/XIX/1a, undated. 40  DDA, McQuaid papers, AB8/B/XIX/1b, undated. 41  Department of Health, Outline of Proposals for the Improvement of the Health Services (Dublin, 1947), p.  16. 42  Report of the Department of Local Government and Public Health 1944–1945 (Dublin, 1945), p. 23. 43  Report of the Department of Local Government and Public Health 1943–1944, p. 39. 44  Ibid., pp. 44–8. 45  L. Price, Dr Dorothy Price: An Account of Twenty Years’ Fight against Tuberculosis in Ireland (Oxford: Oxford University Press, 1957); J. Deeney, To Cure and to Care: Memoirs of a Chief Medical Officer (Dun Laoghaire: Glendale Publishing, 1989); G. Jones, ‘Captain of All These Men of Death’: The History of Tuberculosis in Nineteenthand Twentieth-Century Ireland (Amsterdam: Rodopi, 2001); A. Mac Lellan, Dorothy Stopford Price: Rebel Doctor (Dublin: Irish Academic Press, 2014). 46  John Horgan, Noel Browne; Passionate Outsider (Dublin: Gill & Macmillan, 2000), p. 36.

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Health and disease on the domestic front 47  Ibid., p. 39. 48  Department of Health, Outline of Proposals for the Improvement of the Health Services (Dublin, 1947), p. 8. 49  DDA, AB8/B/XVII, ‘Health Embarkation Scheme Monthly Reports’, 1943–1944. 50  Department of Health, Outline of Proposals, p. 17. 51  Report of the Department of Local Government and Public Health 1943–1944, p. 40. 52  Evans, Ireland during the Second World War, pp. 75–80. 53  L. Ó Broin, Just Like Yesterday: An Autobiography (Dublin: Gill & Macmillan, 1986), p. 142. 54  Report of the Department of Local Government and Public Health 1943–1944, p. 36. 55  Evans, Ireland during the Second World War, p. 36. 56  Report of the Department of Local Government and Public Health 1943–1944, p. 36. 57  Ibid., p. 31. 58  J. Carroll, Ireland in the War Years (New York: Crane Russak, 1975), p. 86. 59  Irish Railway Archives, Great Northern Railway Archives, GM159/11, GM159/16, GM 160/7, ‘Inspection of Great Northern Hotels’, August 1942; ‘Burns to Howden’, 26 March 1943; ‘McCormick to Stewart’, 18 May 1942; ‘McCormick to Stewart’, 9 April 1942; ‘Maguire to manager’, 1 June 1942. 60  Report of the Department of Local Government and Public Health 1943–1944, pp. 34–5. 61  Evans, Ireland during the Second World War, p. 61. 62  National Nutrition Survey Report Part One (Dublin, 1948), p. 14. 63  National Nutrition Survey Report Part Seven (Dublin, 1948), p. 11. 64  National Nutrition Survey Report Part One, p. 18. 65  Ibid., p. 50. 66  Ibid., p. 56. 67  Report of the Tribunal of Enquiry into the Milk Supply (Dublin, 1946), p. 7. 68  Ibid., p. 41. 69  Ibid., p. 82. 70  Ibid., pp. 57–9. 71  Ibid., p. 87. 72  Evans, Ireland during the Second World War, pp. 180–5. 73  Report of the Tribunal of Enquiry into the Milk Supply, p. 80. 74  NAI, Department of Justice, JUS/98/17/5/1/6, ‘Evidence of the Irish Housewives before the Milk Tribunal’, undated. 75  National Nutrition Survey Report Part Two (Dublin, 1948), p. 56. 76  National Nutrition Survey Report Part Three (Dublin, 1948), p. 63. 77  National Nutrition Survey Report Part Four (Dublin, 1948), p. 12. 78  Statistical Abstracts (Dublin), 1940–46. 79  For a historiographical overview, see Evans, Ireland during the Second World War, pp. 1–17.

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4

Alone among neutrals: Ireland’s unique experience of tuberculosis during the Second World War Anne Mac Lellan In 1942, Percy Stocks, medical statistical officer at the General Register Office in England, described tuberculosis as a social barometer rising and falling on the tide of socio-economic circumstances.1 This was particularly the case in Ireland. It is well documented that, in the nineteenth and first half of the twentieth centuries, Ireland had a different experience of tuberculosis to most other European countries: death and infection rates remained considerably higher in Ireland, partly due to high levels of poverty.2 This problem was usually discussed in terms of deaths from tuberculosis. In 1939, there were 3,304 deaths from tuberculosis in Ireland; this rose to 4,347 deaths in 1942. The numbers of those infected or ill with tuberculosis in Ireland were not quantified until the Medical Research Council of Ireland carried out a national survey in 1952. For each death, it was estimated that approximately seven more people were infected with the disease.3 In most European countries, mortality from tuberculosis was in decline by the mid-nineteenth century. However, the Irish epidemic peaked in 1904.4 There is no single reason for Ireland’s unique experience of tuberculosis. In an international context, the role of social and economic factors in the decline of epidemic tuberculosis has been increasingly emphasised since Thomas McKeown, in 1976, challenged the role of medical developments in contributing to falling tuberculosis levels prior to 1935.5 There are competing discourses with respect to the weighting that should be applied to factors such as decreasing virulence of Mycobacterium tuberculosis and Mycobacterium bovis, increased host immunity, better housing, improved nutrition, milk pasteurisation, public health measures, hospital bed provision, X-rays, diagnostic tuberculin testing and curative antibiotics in addition to preventive interventions such as isolation and vaccination.6 Greta Jones’s detailed analysis of the trajectory of Ireland’s tuberculosis epidemic in the nineteenth and twentieth centuries demonstrates the complex interplay of

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the variables that determined the course of the Irish epidemic. These included economic underdevelopment and urbanisation, overcrowding in urban settings, lack of political prioritisation, emigration, poverty, nutrition, infected milk, public health and iatrogenic interventions.7 Whatever the reason (or reasons), from 1904 the number of recorded annual deaths from tuberculosis in Ireland began to fall. It should be noted that the number of registered deaths is undoubtedly an underestimate of actual deaths. Tuberculosis was stigmatising and families sought to manipulate death certificate recordings. As, according to Christopher J. McSweeney, medical superintendent of Cork Street Fever Hospital, Dublin, ‘most [Irish] doctors have had the experience of being urged by the relatives to omit all reference to tuberculosis when assigning the cause of death on an official death certificate’.8 The rate of decline of the Irish epidemic was slow and the proportionate fall in mortality due to tuberculosis in Ireland did not keep pace with other developed countries.9 As shown in Table 4.1, deaths spiked upwards during the First World War and then went into a decline again from 1919 onwards. From 1927 to 1937, Ireland had the lowest annual percentage reduction in tuberculosis mortality among twenty countries in Europe, North America and Table 4.1  Deaths from tuberculosis in Ireland (1913–20 and 1938–48) Year

Tuberculosis deaths (rate per 100,000 population)

1913 1914 1915 1916 1917 1918 1919 1920 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949

210 205 219 211 218 212 188 165 109 112 125 124 147 146 131 125 114 124 104 91

Source: Abstracted from table 2, J. Deeny, Tuberculosis in Ireland: Report of the National Tuberculosis Survey (1950–53) (Dublin: Medical Research Council of Ireland, 1954)

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Australasia.10 From 1939, coinciding with the outbreak of the Second World War, the picture in Ireland worsened as death rates began to rise again as reflected in the figures between 1940 and 1945. By 1942, the tuberculosis death rate had reverted to the death rate of 1926: approximately 147 per 100,000. This translated into more than 4,000 deaths from the disease in one year alone. Then, rates went into decline again. This chapter builds on the observation by contemporary British Medical Research Council scholar Marc Daniels that the rise in tuberculosis deaths until 1942/43 in Ireland meant that it was the ‘only neutral country in Europe to suffer from wartime conditions to this extent’.11 It argues that analysis of tuberculosis in Ireland during the Emergency therefore offers an insight into the uniqueness of wartime disease patterns in Ireland and the responses that they engendered. It also sheds light on the efficacy, and development of, Irish healthcare services in the war and demonstrates that the increased disease burden in the Emergency period encouraged change in post-war health policies. Contextualising Ireland’s experience of tuberculosis during the Emergency How did Ireland’s experience of a spike in deaths from tuberculosis during the Emergency compare with other European countries? In 1949, Daniels published a comparative study of tuberculosis in Europe during and after the Second World War. He observed that the diseases that were traditionally associated with war – typhus, dysentery and typhoid – had not reached ‘anything like their former gravity and distribution’.12 However, tuberculosis death rates rose in every European country ‘seriously affected’ by the war prompting a concern that tuberculosis was going to be Europe’s main post-war public health problem. In relation to England, Percy Stocks, writing in 1942, asserted that the enhanced physical and psychological effects of war had caused an initial wave of hastened deaths of persons already suffering from active tuberculosis. He predicted that this wave might be followed by a secondary – perhaps more long-lasting – wave which would be a delayed result of increased incidence in active respiratory diseases.13 However, this second wave did not come about. Building upon this, a report of the British Medical Research Council on wartime tuberculosis pointed to a number of environmental conditions peculiar to Britain, including the evacuation of many tuberculosis hospitals and sanatoriums in September 1939 to make room for expected air-raid casualties. This meant that many infected persons had returned home. Blackout conditions were reported to have had an adverse effect on ventilation, increasing crossinfection and, perhaps, lowering resistance. Overcrowding followed bombings where people lost their homes. Infected persons may have billeted with uninfected families. Town children had been evacuated to the country where they drank ‘raw’ rather than pasteurised milk.14

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Although Ireland was neutral, and did not experience the same disruption to civilian society, Irish experience of tuberculosis during the Emergency, in terms of an early rise in the death rate, was broadly similar to the British experience, with an initial wave of deaths peaking in 1942. While the rise in tuberculosis death rates in Ireland mirrored the British experience, the factors that were supposed to have underpinned the rise in British rates did not come into play in the Irish context. Daniels placed European countries into three groups depending on their experience of tuberculosis mortality during the Second World War. The first group consisted of countries with little or no rise in the disease; the second group of countries that saw a rise in the early years of the war followed by a continuous fall; and a third group that witnessed a rise in the latter part of the war.15 His maps showing the tuberculosis death rate in European countries before and after the war are reproduced in Figures 4.1 and 4.2.

Figure 4.1  Tuberculosis mortality in Europe, 1938

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Ireland’s experience of TB during Second World War

Figure 4.2  Tuberculosis mortality in Europe, 1946

The maps suggested that death from tuberculosis rose in Holland, Austria, Hungary, Germany and Poland through the war years. Rates in these countries peaked at the end of the war. Daniels demonstrated that Denmark, with the lowest tuberculosis mortality in Europe, experienced little or no wartime rise in deaths. In Norway and Sweden, death rates from tuberculosis actually fell during wartime. Daniels grouped England and Wales, Belgium, France and Ireland together as countries which experienced a rise in tubercular deaths in the first years of the war and then a falling off. The rise in the tuberculosis death rate in Ireland during the Emergency has been scrutinised by Greta Jones. However, Jones does not emphasise the singularity of Ireland’s experience in terms of being a neutral country. According to Daniels, Ireland was ‘apparently the only neutral country in Europe to suffer from wartime conditions to this extent’.16 It is important to note that the statistics underpinning these so-called ‘waves of death’ must be approached cautiously. Daniels was blunt about the accuracy of available statistics: ‘when one presents statistics of tuberculosis in Europe it is with a feeling that they are better than no

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information at all but not much better’. The statistics he used were those obtainable in ‘the circumstances of war’.17 While death and dying are a leitmotif of the tuberculosis story, it is often forgotten that many infected persons fell ill but did not die. Instead, they struggled through a protracted, painful and often frightening illness. The increase in deaths was accompanied by an unquantified increase in non-fatal illness. The heightened visibility of tuberculosis in Ireland during the Emergency was not just evident in dry tables of numbers and maps prepared during and following the war. As pointed out by Clair Wills, contemporaneous literature written by Irish authors such as Maura Laverty and Mártín Ó Cadhain also provoked an emotional response.18 In 1942, Laverty’s novel, although fictional, was referred to in a Dáil debate on tuberculosis. Wills is of the opinion that ‘tuberculosis became the symbol of the government’s failure to tackle social deprivation and poverty’.19 The general misery of the urban poor, and in particular the slum dwellers, who were at high risk of contracting tuberculosis in overcrowded conditions was highlighted by a paediatrician-turned-playwright, Robert Collis. In 1939, he wrote the relentlessly tragic play Marrowbone Lane which was put on in the Gate Theatre, Dublin, in 1939 and 1941.20 Although tuberculosis was often construed as a disease that affected the lungs of adults, there were other forms of the disease – notably bone, joint, meningeal and miliary tuberculosis – which were particularly prevalent in children. The Emergency seemed to have exacerbated Irish children’s as well as adults’ experience of tuberculosis. Table 4.2 shows that deaths from tubercular meningitis among children under 5 years of age increased significantly

Table 4.2  Deaths from meningeal tuberculosis in Irish children (1938–50) Year

No. of meningeal tuberculosis deaths (children under 5 years)

1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950

67 77 83 114 97 123 118 138 128 140 118 88 87

Source: Annual Reports of the Registrar General 1938–50 (Dublin: Government Stationery Office)

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in the first half of the 1940s, although the death rate did not rise in a straightforward manner. Historian Roger Cooter has examined the history of ideas of war and epidemics in an article entitled ‘Of War and Epidemics: Unnatural Couplings, Problematic Conceptions’. He asserts that the problem with associating wars and epidemics lies in the distortion it creates by suggesting that non-wartime demographic regimes are static. He further posits that even if we were able to construe war as a discrete event, we ought not to overestimate its importance, for war itself is woven within wider, more densely knit demographic/pathogenic and sociopolitical systems.21 However, in the case of the Second World War, despite reservations about the ‘absolute validity’ of figures, Daniels demonstrated that the ‘increase in tuberculosis was related to deterioration in conditions so closely, in time and in gravity, as to constitute a remarkable index of the wartime tribulations of those countries’.22 In summary, it seems evident that Ireland’s experience of tuberculosis during the Second World War was broadly similar to the experience of Britain which was a combatant country rather than the experience of other neutral counties, complicating efforts to link war to shifting epidemiological patterns. The increased number of deaths in Ireland rendered the disease visible and began to provoke a response at national level. Vitamins and their agonists: flour extraction and tuberculosis How did Irish responses to the Second World War impact on tuberculosis death rates? Factors including diet and a poor public health infrastructure seem to have played a role in the rising death rate. The effects of flour extraction on Irish children’s health during the Emergency have been largely framed in terms of rickets.23 However, it seems likely that changes in flour production also exacerbated Irish childhood experience of, and susceptibility to, tuberculosis. Between September 1940 and February 1942, restrictions on imported wheat prompted an increase in the extraction rate of flour. The extraction rate eventually reached 100 per cent and the resulting bread was coarse and brown in colour. To worsen matters, imports of cod liver oil and other concentrated sources of vitamin D rapidly decreased as a result of wartime trade disruption. In December 1942, there were acrimonious exchanges in the Dáil Éireann with respect to the merits of the fortification of this coarse brown bread with calcium. Deputy John Dillon drew the attention of Con Ward, the parliamentary secretary for the Department of Local Government and Public Health, to the recently published work of ‘McCance, of Cambridge’24 on the adverse effect of phytic acid in bread made of ‘100 per cent extraction wheaten flour on calcium metabolism’.25 Dillon asked whether the minister would arrange to have adequate quantities of calcium added to flour manufacture in Ireland to overcome the nutritional dangers consequent on calcium insufficiency in

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the national diet. In response, Ward adamantly insisted that there ‘is no clinical evidence available of the adverse effect of high extraction or that the problem would be solved by the addition of calcium to the flour’.26 In May 1943, the public argument continued when Dillon reasserted that there had been an ‘immense increase’ in rickets which was directly attributable to ‘the 100 per cent extraction of wheaten flour’ which contained ‘phytic acid in appreciable quantity’. The phytic acid prevented calcium metabolism and the resulting inadequacy of calcium metabolism resulted in rickets in children. Dillon suggested that the easiest way to correct this would be to ‘reduce the flour extraction to ninety per cent – because the phytic acid occurs mainly in the last ten per cent extraction from the wheat – or, if the circumstances demand that you should maintain 100 per cent extraction, that you should add to the flour calcium carbonate’.27 In October 1943, Dillon once again highlighted the issue, this time suggesting that in addition to playing a role in the increase in rickets, the bread was injuring the health of expectant women.28 Although the debate about the effects of diet, and in particular, the coarse unsupplemented loaf was largely framed in terms of rickets, the Emergency loaf was also implicated in the increased incidence and severity of tuberculosis in Irish children. Dorothy Price, an Irish childhood tuberculosis expert working in St Ultan’s Infants Hospital in Dublin was dismayed at the increased severity of tubercular lesions that she was seeing and their lack of healing. From mid 1942, she and her fellow paediatricians observed that cases were coming into the hospital with ‘spreads and extensions of lesions, other than primary tuberculosis, such as we had not been seeing since about 1933–34’.29 Not only this, but St Ultan’s inpatients were experiencing a spread of the disease into areas such as the humerus or the spine. After three months, Price began to wonder if the brown bread ‘could be at fault’ for causing a marked increase in rickets in young children. She was concerned that there was ‘some factor, probably phytic acid, which interferes with absorption of calcium in the young child which leads in consequence to the non-healing of primary tuberculosis, in that calcium deposits in the focus and glands do not take place at the normal rate’.30 Price informed W. J. E. Jessop, professor of physiology and biochemistry at the Royal College of Surgeons of Ireland, of difficulties with the spread and non-healing of tuberculous lesions in children in St Ultan’s.31 He suggested that calcium should be administered with the bread meals in order to engage the phytic acid in the bread. He also proposed that the vitamin D allowance per day be doubled and that plenty of milk be given apart from the bread meals. St Ultan’s began to give 1,000 to 1,500 international units of vitamin D daily, according to the stage of the tuberculous lesion. They gave five to ten grains of calcium eaten in tablet form after breakfast and tea, in addition to one and a half to two pints of milk daily, besides ‘a good mixed diet which includes sufficient protein for children under five years according to their age’. Cod liver oil was administered. In the outpatients department, tuberculous

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Ireland’s experience of TB during Second World War

children were also given calcium, vitamin D and milk. Price expressed herself as ‘very happy with the alteration to the regime – a regime which has as it basis the supposition that there is some factor in the brown bread which interferes with the normal absorption of calcium in the young child’.32 To date, studies of the role of nutrition on childhood tuberculosis are significantly limited. However, malnourishment is regarded as a ‘high risk’ for tuberculosis and nutritional supplementation is commonly used. The role of vitamin D receptors with respect to immunity and development of tuberculosis has been investigated.33 While vitamin D may help prevent infection, calcium was seen by Price as necessary in the healing process to ‘wall off’ the tuberculosis lesion successfully. The brown bread in Ireland remained unfortified for most of the Emergency. Then, in 1944, Professor R. A. Cance and his collaborator E. M. Widdowson pointed out the value of fortifying bread with calcium to an audience in the Royal College of Physicians of Ireland in Dublin which included the Taoiseach Éamon de Valera and Ward.34 In November 1944, the rate of extraction of flour in Ireland was lowered from 100 to 85 per cent.35 In 1948, noting the experience in Ireland during the Second World War, Cance stated that the British decision to add calcium to flour was well justified.36 In Denmark, where the usual form of bread was rye, arguments about extraction rates were not so relevant.37 In Norway, calcium requirements were fulfilled during the Second World War with the possible exception of 1942. From 1943 to 1946, bread was supplemented with calcium carbonate.38 In Sweden, which, like Ireland, remained neutral, meat consumption decreased by 75 per cent but there was ‘little evidence of malnutrition’ and the death rate from tuberculosis remained low.39 In Ireland, it would seem that contemporary concerns about declining nutritional health during wartime encouraged doctors such as Price to consider the effects of poor-quality bread on the progress of tubercular disease. Price and Jessop’s research appear to indicate that the rate of flour extraction in Ireland was important in terms of tuberculosis in addition to rickets. Diagnosis and prevention of tuberculosis While diet undoubtedly played an important part in the epidemiology of tuberculosis in the Second World War, difficulties in diagnosing the disease and a lack of engagement with preventive vaccination also exacerbated the problem. It has been noted that, for nearly one hundred years, the diagnosis of tuberculosis in the western world has relied on the fulfilment of at least three of four criteria – ‘compatible symptoms, close exposure to a contagious case of tuberculosis, compatible x-ray finding and a positive tuberculin skin test. Ideally, the diagnosis is confirmed by a positive culture of either Mycobacterium tuberculosis or, rarely, Mycobacterium bovis’.40 Diagnosis of tuberculosis in Irish children and adults was somewhat ‘hap-hazard’ in the years

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preceding and during the Emergency.41 There was a lack of hospital laboratories and x-ray equipment.42 Tuberculin testing was not widely used, even though it did not require elaborate equipment. The consequences included a lack of treatment for tubercular patients whose diagnosis had been missed and inappropriate treatment (such as prolonged periods – sometimes several years – in hospitals or sanatoriums), for non-tubercular patients who had been mistakenly deemed tubercular. At community level, a lack of contact tracing allowed for the unchecked development of micro-epidemics in institutions, families and housing clusters.43 In contrast, in Sweden, tuberculin testing was widely used. In addition, mass screening of the population using miniature radiography continued during the Second World War. From 1940, all conscripts to the defence forces were examined using this technique. From 1942, the Swedish National Anti-Tuberculosis Society also organised mass miniature radiography campaigns. From 1944, the diagnostic tuberculin test was made obligatory by law in certain types of schools.44 The use of the tuberculin test in Sweden made case finding much more efficient. Early cases of tuberculosis were seen as easier to treat while the isolation of infectious cases relied on detection. Ireland’s ability to deal with rising tuberculosis rates during the Second World War was undoubtedly hampered by a comparable lack of efficient case finding processes. In addition to a lack of engagement with tuberculin testing for diagnosis, vaccination against tuberculosis was not part of the government or medical profession’s response to the rise in tuberculosis during the Emergency. BCG vaccine had been developed in France by Albert Calmette and Camille Guérin and first made available for clinical use in the early 1920s. It was controversial. The statistics produced by Calmette about the efficacy of the vaccine were later shown to be unreliable. A vaccine disaster occurred in Germany in late 1929 and early 1930 when seventy-seven infants died of tuberculosis following vaccination with a substance that purported to be BCG.45 In addition, issues such as nationalism, politics, the availability of hospital and sanatorium beds as well as investment in public health infrastructure seemed to have influenced attitudes towards BCG in countries such as Britain, the United States, France, Norway and Sweden.46 Throughout 1937 and 1938, Dorothy Price, who had developed direct links with Professor Arvid Wallgren, the main proponent of BCG in Sweden, began to experiment with the preventive BCG vaccine in Dublin. This relatively safe but controversial vaccine, which is estimated to provide 80 per cent protection in the general population, was particularly efficacious with respect to tubercular meningitis in children. Price imported a liquid vaccine from Sweden, which was flown in, and had to be used within a very short time span. Supplies of the vaccine became unavailable during the Emergency. However, Price continued to canvass public, political and medical opinion in favour of introducing mass BCG when the war ended.

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Sweden, which was one of the pioneer countries with respect to BCG vaccination, continued its programme of vaccination throughout the Second World War. Finland which had begun to use BCG flown from Sweden weekly was able to continue its programme of vaccination and in 1943, according to Helene Laurent, more than 10,000 Finnish army recruits were vaccinated.47 In Germany, the Weimar Republic was initially in favour of BCG vaccination but the vaccination tragedy in Lübeck put an end to the programme. In occupied Norway, the continuance of BCG vaccination was seen as a symbol of national resistance.48 In Britain, as in Ireland, mass BCG campaigns post-dated the Second World War. BCG vaccination was later to prove particularly effective with respect to preventing tubercular meningitis in Irish neonates and children. Evidently, a reluctance to engage with tuberculin testing for diagnosis and with BCG vaccination for prevention of the disease contributed to the high tuberculosis rate in Ireland during the Emergency. Pressure groups: an Irish national anti-tuberculosis league and the Irish Red Cross How did the Irish medical profession respond to the rise in tuberculosis death rates? Was their response effective? In 1939, Wallgren suggested to Price that Ireland might benefit from a national voluntary anti-tuberculosis league similar to that operating in Sweden.49 Ireland was unusual in that it did not have this type of organisation – earlier attempts had foundered with the foundation of the new state. The last such attempt had been made three decades previously by the [British] National Association for the Prevention of Tuberculosis (NAPT) and by the vicereine Lady Aberdeen’s Women’s National Health Association (WNHA). Greta Jones notes that the WNHA and NAPT were among the last voluntary all-Ireland organisations to tackle a health problem.50 Many other European countries and the United States had set up leagues in the late 1800s soon after it had been demonstrated that tuberculosis was caused by a bacterium. The leagues were usually charitable ventures, run by the laity with some medical input. They worked to raise public awareness as well as funds to instigate palliative, preventive and curative programmes.51 In 1942, with tuberculosis deaths peaking and lesions from the disease worsening, Price set about founding such a league. The newly proposed league was to include both medical and lay people. It placed an emphasis on medical intervention including improved diagnosis, better bed provision, as well as the use of tuberculin testing, X-rays and BCG vaccination. Over the course of a year, Price brought together a group that included professors of medicine from Irish universities, representatives of the county medical officers of health, various tuberculosis experts as well as politicians and public figures. The group also contained representatives of professional groups such as the secretary of the National Health Insurance Society, the secretary of the Irish Drug

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Association and the president of the veterinary association. The chairman of the group was the TCD Professor Robert Rowlette while Price, another Protestant and Trinity College Dublin graduate, served as joint secretary. The multi-denominational group was intended as a cross-border organisation. Brice Clarke, chief tuberculosis officer at Whiteabbey and Graymount sanatoriums in Co. Antrim, planned to open up groups in Northern Ireland. Although cross-border and cross-denomination support for the league existed there, it was short-lived.52 Religious tensions disrupted the proposed plans. In February 1943, the proposed league held its first public meeting. The Catholic Archbishop of Dublin, John Charles McQuaid, through his proxy, Monsignor Daniel Moloney, sent an unequivocal message to the meeting. It was the archbishop’s ‘definite opinion’ that a national anti-tuberculosis campaign should be ‘carried on in Éire’ under the guidance of the Irish Red Cross rather the assembled group.53 He wished to see the anti-tuberculosis drive led by Catholics rather than Protestants. At his insistence the proposed league was subsumed within the Irish Red Cross early in 1943.54 The anti-tuberculosis section of the Irish Red Cross initially displayed much energy, instigating a national survey with respect to diagnosis and treatment of tuberculosis. It also produced propaganda including a series of six leaflets which were variously designed to educate the public, to provide model lectures for doctors and to promulgate the society’s long-term plans for prevention, aftercare, rehabilitation and sanatoriums. By 1945, up to 70,000 copies of these leaflets were distributed. Propaganda films were screened with an audience of 100,000 reached. The anti-spitting posters were so popular they had to be reprinted. As well as education and lobbying, there was some concrete or bricks and mortar results from both campaigns. The Red Cross was a beneficiary of the Irish Hospital Sweepstakes from 1940 to 1944 and money was made available to the anti-tuberculosis section. A preventorium in Ballyroan near Tallaght was established and the section paid contributions towards an extension at the children’s tuberculosis hospital in Fairyhill in Howth, Co. Dublin, and an experimental hut in the Meath General Hospital. However, by 1946, Price had left the Red Cross and two other stalwarts, T. W. T. Dillon and Rowlette, who had been part of Price’s earlier group, had died. In March 1948, James Deeny, the chief medical adviser, rather unkindly commented that the Irish Red Cross began a short programme of work and then folded up. Nonetheless, Jones credits the attempt to start a national anti-tuberculosis league in 1942 with prompting the beginnings of a political awakening with respect to tuberculosis.55 The attempt to found a league was pivotal in terms of the publicity it generated with respect to the issue of tuberculosis. In addition, the members of the proposed league, in their new role in the Red Cross, continued to provoke a response from government officials as well as media (as expanded upon below). The attempt to found a league was, as Jones observes, the beginning of a new

Ireland’s experience of TB during Second World War

determination to tackle the disease in light of heightened wartime concern about rising incidence rates.

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Tuberculosis politicised Ruth Barrington correctly states that, by the end of 1944, the ‘universal apathy’ towards tuberculosis in Ireland seemed to have lifted. She credits the appointment of the energetic Deeny as chief medical adviser to the Department of Local Government and Public Health with precipitating a breakthrough.56 A dynamic man, he acted as a catalyst for changes in policy and practice with respect to tuberculosis. Jones goes further, stating that by the mid 1940s, tuberculosis took on ‘an iconic significance in the push for social reform’. In his memoirs, Deeny recalled that the Red Cross (and in particular Dillon) had been irritating him with their nuisance drive and he ‘let go’ and committed the government to ending tuberculosis.57 There was a sense of pent-up frustration in the department with respect to the need to build new hospitals and sanatoriums or convert old buildings; ideas stymied by a lack of building supplies. In private correspondence the department’s tuberculosis inspector E. J. T. McWeeney wrote in 1945 that ‘if only this damned war would get itself finished we’d go places in anti-TB work’.58 With the end of the war, the pace of the department’s work with respect to tuberculosis accelerated. The wartime rise in tuberculosis death rates, the attempt to found a national anti-tuberculosis league and the subsequent publicity made tuberculosis a high priority for the department. A White Paper on tuberculosis was published in 1946 – the main emphasis was on bed provision although the need for new X-ray and lab facilities was acknowledged. With the end of the war, the availability of building materials allowed an ambitious programme of sanatorium building to commence. By the late 1940s, tuberculosis had become a hugely emotive political issue, forming the main plank of Noel Browne’s election campaign, which, like the 1946 White Paper was focused on bed provision. By the early 1950s, the advent of effective triple therapy for tuberculosis, the beginnings of a mass BCG campaign, a better diet with flour with adequate calcium and vitamin D together with improving socio-economic conditions, rendered the bed programme a white elephant. By the end of the 1950s, the tuberculosis epidemic in Ireland came to an abrupt end and the sanatoriums had to be redeployed for other purposes. Conclusion Ireland was the only neutral European country to experience a marked rise in the tuberculosis death rate during the Second World War. The spike in deaths from tuberculosis in Ireland during the Emergency was significant, and unique, in demographic terms and constituted a discrete event when set against a

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background of a mortality curve that was not static but was continuously, albeit slowly, falling. Pinpointing the exact reasons for the rise in deaths from tuberculosis during the Second World War is difficult, if not impossible. According to an editorial in the British Medical Journal in 1949, ‘in spite of the mass of information available many of the wartime and post-wartime trends in tuberculosis cannot be satisfactorily explained’. It remains a moot point as to whether deaths from tuberculosis were due to new infections or to the ‘aggravation of disease from which patients would ordinarily have recovered’.59 Roger Cooter’s observation of the death rate during wars being woven into wider circumstances is certainly true of Ireland’s experience of tuberculosis and the Emergency. Sweden, which was also neutral, had a lower pre-war death rate and more robust and established anti-tuberculosis programmes which focused on diagnosis and prevention in addition to bed provision and treatment. Nutrition in Sweden also remained relatively satisfactory during the war. Unsurprisingly, Sweden fared better than Ireland with respect to its tuberculosis death rate during the war. While bearing in mind the crude nature of the available statistical evidence and the difficulties in interpreting these statistics, this chapter has highlighted some factors that underlay Ireland’s experience of tuberculosis in the Emergency. Both adults and children experienced an increased death rate and there is some evidence that the severity of the disease was increased in children who were particularly susceptible to dietary changes. This chapter has argued that the decrease in calcium and vitamin D, which has previously been framed in terms of the development of rickets in Irish children, was also considered important in terms of childhood tuberculosis. An underdeveloped tuberculosis service with inadequate diagnostic equipment and paradigms, an aversion to the use of preventive vaccine and an insufficiency of hospital or sanatorium beds for tubercular patients together with a large burden of disease, poor socio-economic circumstances and overcrowded urban housing, a lack of a national antituberculosis league and an ill-advised flour extraction policy provide some clues as to Ireland’s spike in the tuberculosis death rate. Barrington states that the Emergency in Ireland was a ‘dividing line in the development of health services’.60 This was particularly true with respect to tuberculosis which had become highly politicised.61 Whatever the reason or reasons, the increased visibility of tuberculosis in Ireland during the Emergency, amplified by newspaper coverage and sentimentalised in literature, coupled with the controversy over the attempt to found a national anti-tuberculosis league led to a turning point in policy and practices with respect to the disease. Notes   1  P. Stocks, ‘Tuberculosis deaths and the war’, British Medical Journal, ii (26 December 1942), 750–1.

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Ireland’s experience of TB during Second World War   2  R. C. Geary, ‘The mortality from tuberculosis in Saorstát Éireann: a statistical study’, Journal of the Statistical and Social Inquiry Society of Ireland, 14:7 (1929/30), 67–103; J. Deeny, Tuberculosis in Ireland: Report of the National Tuberculosis Survey 1950–53 (Dublin: Medical Research Council, 1954); G. Jones, ‘Captain of All These Men of Death’: The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (Amsterdam and New York: Rodopi, 2001).   3  T. W. T. Dillon, ‘The statistics of tuberculosis’, Irish Journal of Medical Science, 6:199 (July 1942), 238.   4  Jones, ‘Captain of All These Men of Death’, p. 2.   5  T. McKeown, The Modern Rise of Population (London: Edward Arnold, 1976), p. 153.   6  See, for instance, L. Bryder, Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain (Oxford: Oxford University Press, 1988); F. B. Smith, The Retreat of Tuberculosis 1850–1950 (London, New York and Sydney: Croom Helm, 1988); N. McFarlane, ‘Hospitals, housing and tuberculosis in Glasgow, 1911–51’, Social History of Medicine, 2 (April 1989), 59–85; G. D. Feldberg, Disease and Class: Tuberculosis and the Shaping of Modern North American Society (New Brunswick: Rutgers University Press, 1995); S. Szreter, ‘Economic growth, disruption, deprivation, disease and dearth: on the importance of the politics of public health for development’, Population and Development Review, 23:4 (December 1997), 693–728; M. Gandy, ‘Life without germs’, in M. Gandy and A. Zumla (eds), The Return of the White Plague: Global Poverty and the ‘New’ Tuberculosis (London and New York: Verso, 2003); P. Weindling, ‘From germ theory to social medicine’, in D. Brunton (ed.), Medicine Transformed: Health, Disease and Society in Europe 1800–1930 (Manchester: Manchester University Press, 2004); M. Niemi, Public Health and Municipal Policy Making: Britain and Sweden 1900–1940 (Aldershot and Burlington: Ashgate, 2007).   7  Jones, ‘Captain of All These Men of Death’.   8  C. J. McSweeney, ‘Some public health aspects of tuberculosis’, Irish Journal of Medical Science, 6:199 (July 1942), 250; J. E. Counihan and T. W. T. Dillon, ‘Irish tuberculosis death rates: a statistical study of their reliability, with some socio-economic conditions’, Journal of the Statistical and Social Inquiry Society of Ireland, 17:1 (1943/44), 169–88.   9  Counihan and Dillon, ‘Irish tuberculosis death rates’, 169. 10  Ibid.; R. J. Rowlette, ‘Tuberculosis in Éire’, Irish Journal of Medical Science, 6:199 (July 1942), 221–43. 11  M. Daniels, ‘Tuberculosis in Europe during and after the Second World War’, British Medical Journal, ii (12 November 1949), 1065–72, 1067. 12  Ibid., 1065. 13  Stocks, ‘Tuberculosis deaths and the war’, 750–1. 14  Medical Research Council, Report of the Committee on Tuberculosis in Wartime (London: HM Stationery Office, 1942). 15  Daniels, ‘Tuberculosis in Europe’, 1067. 16  Ibid. 17  Ibid., 1065. 18  C. Wills, That Neutral Island: A Cultural History of Ireland during the Second World War (London: Faber and Faber, 2007), p. 298 and p. 334. 19  Ibid., p. 262. 20  R. Collis, Marrowbone Lane (Dublin: Runa Press, 1943). 21  R. Cooter, ‘Of war and epidemics: unnatural couplings, problematic conceptions’, Social History of Medicine, 16:2 (August 2003), 238–302. 22  Daniels, ‘Tuberculosis in Europe’, 1065–72.

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Health and disease on the domestic front 23  L. Kelly, ‘Rickets and Irish children: Dr Ella Webb and the early work of the Children’s Sunshine Home, 1925–1946’, in A. Mac Lellan and A. Mauger (eds), Growing Pains: Childhood Illness in Ireland 1750–1950 (Dublin: Irish Academic Press, 2013). 24  C. S. Breathnach and J. B. Moynihan, ‘Robert Alexander McCance, and his forays into experimental medicine with Elsie Widdowson’, Ulster Medical Journal, 83:2 (May 2014), 111–15. 25  ‘Addition of Calcium to Flour’, Dáil Éireann Debates (10 December 1942), vol. 89, no. 2. 26  Ibid. 27  ‘Dietetic Quality of Flour’, Dáil Éireann Debates (13 May 1943), vol. 90, no. 2. 28  ‘Vote 30 – Agriculture’, Dáil Éireann Debates (21 October 1943), vol. 91, no. 7. 29  Trinity College Dublin (hereafter TCD) archives, Dorothy Stopford Price papers, 7536/419. ‘Notes written by Dorothy Price; Possibly a Draft of an Article or Letter’, October 1943. 30  Ibid. 31  TCD archives, Dorothy Stopford Price papers, 7536/410. ‘Letter from D. Price to W. J. E. Jessop’, 26 October 1943. 32  Ibid. 33  D. Jaganath and E. Mupere, ‘Childhood tuberculosis and malnutrition’, Journal of Infectious Diseases, 206 (December 2012), 809–15. 34  ‘Scientists’ Diet Tests with Bread’, Irish Times (21 January 1944), p. 1. 35  Connaught Tribune (14 October 1944), p. 6. 36  ‘Anti-vitamins: Nutrition Society conference’, British Medical Journal, ii (27 November 1948), 952–4. 37  ‘Reports of societies: post-war conference on nutrition’, British Medical Journal, ii (17 August 1946), 236–7. 38  G. Toverud, ‘The influence of war and post-war conditions on the teeth of Norwegian school children’, Millbank Fund Quarterly, 35:4 (October 1956), 389–90. 39  ‘Reports of societies’. 40  R. Bennett and M. Eriksson, ‘Childhood tuberculosis in the western world’, Infectious Diseases, 3 (2002), 4–26. 41  J. Duffy, ‘Review of pulmonary tuberculosis in practice’, Journal of the Irish Free State Medical Union, 1:6 (December 1937), 72; M. Crowe, ‘Local authority tuberculosis schemes: suggestions for their better development’, Irish Journal of Medical Science, 6:33 (May 1945), 153–8; Tuberculosis (Dublin: Stationery Office, 1946), p. 16; J. A. Deeny, ‘Aspects of the problem in Éire’, Irish Journal of Medical Science, 6:252 (December 1946), 774–8; J. Deeny, To Cure and to Care: Memoirs of a Chief Medical Officer (Dun Laoghaire: Glendale Publishing, 1989), pp. 99–100. 42  Tuberculosis, p. 16. 43  A. Mac Lellan, ‘The penny test: tuberculin testing and paediatric practice in Ireland, 1900–1960’, in Mac Lellan and Mauger (eds), Growing Pains, p. 126. 44  ‘Tuberculosis in Sweden and the fight against tuberculosis in recent years’, Public Health Reports (1896–1970), 61:23 (7 June 1946), 826–9. 45  ‘The Lübeck disaster: a general review’, British Medical Journal, 1:3674 (6 June 1931), 986–7; Bryder, Below the Magic Mountain, p. 139; L. Bryder, F. Condrau and M. Worboys, ‘Tuberculosis and its histories: then and now’, in F. Condrau and M. Worboys (eds), Tuberculosis Then and Now: Perspectives on the History of an Infectious Disease (Montreal: McGill-Queen’s University Press, 2010), p. 15. 46  See, for instance, Smith, The Retreat of Tuberculosis, pp. 194–203; L. Bryder, ‘We shall not find salvation in inoculation: BCG vaccination in Scandinavia, Britain and

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Ireland’s experience of TB during Second World War the USA, 1921–1960’, Social Science and Medicine, 49:9 (November 1999), 1157–67; Feldberg, Disease and Class, pp. 125–52. 47  H. Laurent, ‘War and the emerging social state: social policy, public health and citizenship in wartime Finland’, in V. Kivimäki and T. Kinnunen (eds), Finland in World War Two: History, Memory, Interpretations (Leiden: Brill, 2011), p. 337. 48  TCD archives, Dorothy Stopford Price papers, 7537/180, ‘Unpublished paper: E. J. T. McWeeney, The Employment of BCG Vaccine in Ireland’; G. Hertzberg, ‘Recent experiences with BCG vaccination in Norway’, Tubercle, 28:1 (January 1947), 1–9. 49  TCD archives, Dorothy Stopford Price papers, 7534/57, ‘Letter from A. Wallgren to D. Price’, 30 May 1939. 50  Jones, ‘Captain of all these Men of Death’, p. 119. 51  Bryder, Below the Magic Mountain, pp. 15–17. 52  A. Mac Lellan, Dorothy Stopford Price: Rebel Doctor (Dublin: Irish Academic Press, 2014), pp. 165–94. 53  Irish Times (16 February 1943), p. 1; Irish Independent (16 February 1943), p. 3; J. Cooney, John Charles McQuaid: Ruler of Catholic Ireland (Dublin: O’Brien Press, 1999), p. 164. 54  Mac Lellan, Dorothy Stopford Price, pp. 165–94. 55  Jones, ‘Captain of All These Men of Death’, p. 196. 56  R. Barrington, Health, Medicine and Politics in Ireland 1900–1970 (Dublin: Institute of Public Administration, 1987), pp. 161–4. 57  Deeny, To Cure and to Care, p. 128. 58  TCD archives, Dorothy Stopford Price papers, 7537/56, ‘Letter from T. McWeeney to D. Price’, 27 April 1945. 59  ‘Tuberculosis and war’, British Medical Journal, ii (19 November 1949), 1160–1. 60  Barrington, Health, Medicine and Politics, p. 137. 61  Jones, ‘Captain of All These Men of Death’, p. 200.

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PART II:

Health and political unrest

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5

War on our doorstep: Temple Street Hospital and the 1916 Rising Barry Kennerk

To date, numerous books and articles have been written about the Easter Rising of 1916 and a growing number of historians have begun to assess how this conflict affected civilian life.1 Fearghal McGarry has consulted Bureau of Military History witness statements to portray the gritty reality of urban warfare,2 while Stephen Ferguson has cited British Postal Museum papers and other sources to recount how telegraph staff mounted an initial defence against the rebels.3 Mick O’Farrell has printed extracts from the diaries of ‘ordinary’ Dubliners.4 However, aside from Anthony Kinsella’s article, ‘Medical Aspects of the 1916 Rising’ we still know very little about what happened to those who were wounded.5 Such analysis, in so far as it is possible, could facilitate a broader understanding of the non-political aspects of the Easter Rising, shed further light on the under-analysed role of the clinician in revolutionary-period Ireland and expand upon a burgeoning interest in the history of Irish paediatric medicine.6 This chapter focuses on the medical aspects of the Easter Rising, with a particular emphasis on the young. The injuries inflicted on children and adolescents during the conflict remains under-analysed and yet this group was arguably the most vulnerable category of non-combatants. Analysis of their experiences and medical treatment significantly contributes to our understanding of civilian life during the Rising.7 Through curiosity or a sense of adventure, children wandered through the heart of Dublin and risked death or injury as they played games, looted shops or simply climbed buildings to get a better view of the fighting.8 Moreover, the Easter Rising occurred in a period when concern about the well-being of the underprivileged was high. As Margot Backus argues, sentiment towards childhood had risen dramatically since the late nineteenth century. By the 1910s, the children of the urban poor had become socially visible; images of the ‘endangered Irish urban child’ having proliferated during the Dublin Lockout of 1913.9

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This chapter uses Dublin’s Temple Street Children’s Hospital, a small voluntary institution that catered for the city’s tenement poor, as a case study to explore two interconnected themes: first, the extent to which the temporary reorganisation of medical services during the First World War left Dublin’s hospitals better prepared to cope with the 1916 Rising and, second, how conflict promoted development in medical knowledge and the rapid mobilisation of a proactive health service. The period in question witnessed high concern about Irish childhood. Janet Dunwoody has observed that Irish participation in the war lent a much needed, but perhaps unforeseen, impetus to the issue of child welfare, drawing attention to health issues affecting babies born into slum conditions. The condition of these infants – many of whom attended Temple Street during the war, was also highlighted by the hospital authorities whose baby clubs bore many similarities to the public health nurse scheme of later years.10 In Chapter 1 in this volume, Fionnuala Walsh has considerably expanded upon this theme. It might be argued that in the aftermath of Easter Week the shooting of children on the streets of Dublin helped to bolster the claim that young lives were just as important as those of soldiers fighting on the front. As a secondary theme, this chapter shows how the 1916 conflict gave Irish doctors first-hand experience in the treatment of gunshot wounds, thus contributing to domestic medical advances far from the battlefields of France. Paediatric gunshot injuries in Ireland prior to the Easter Rising Conflict has often acted as a spur to mechanical innovation. During the First World War, the pace of change in weapons and ballistics technology presented a significant challenge to physicians employed in arenas of conflict. Internationally, many of them wrote new or updated textbooks, including prominent American brain surgeon William Williams Keen and American surgeon Vilray P. Blair.11 Nonetheless, historians have often overlooked the extent to which surgeons working in civilian practice could also be inventive, particularly those who found themselves having to deal with casualties resulting from civil disturbance or industrial accidents.12 Britain, which had steel and coal mining districts, produced a steady stream of trauma casualties but Ireland, with its largely agricultural economy, was not so conducive to surgical learning. Thus, from a purely clinical standpoint, the 1916 Rising represented an important opportunity for civilian doctors to implement new techniques. Prior to Easter Week, paediatric gunshot injuries, although rare, were not unknown in Ireland.13 Most were accidental – in many cases involving fowling pieces or toy pellet guns and were frequently non-fatal (i.e. caused by small, low-velocity firearms).14 Present-day surgeons consider any pro­ jectile with a velocity of 330 m/s to be low or subsonic. Practically all modern weapons have bullet speeds that are considerably higher.15 By contrast,

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Temple Street Hospital and the 1916 Rising

mid-nineteenth-century handguns such as the Colt revolvers used during the American Civil War had muzzle velocities of just 230–260 m/s and their powder and ball predecessors had velocities of 167 m/s or less.16 Many of these weapons circulated in Dublin during the late nineteenth century. Unlike today’s high-velocity bullets, nineteenth-century balls produced almost little or no cavitation (a kinetic shockwave that causes serious tissue damage) and, being slower moving, they were liable to lodge in unusual locations at odds with their trajectory. In 1881, the British Medical Journal reported a case involving a 14-year-old boy from Co. Antrim who sustained a maxillary injury at relatively close range. His friend told the operating surgeon that ‘he was very much afraid he had shot him, about half an hour before, with a revolver’.17 The child recovered remarkably well from his injuries. By 1916, the propensity for firearms to cause lethal damage had increased significantly. The widespread use of smokeless propellants such as cordite meant that it was now possible to achieve far higher muzzle velocities and flatter trajectories than had been feasible with black powder. Such innovations were accompanied by developments in machine gun technology which used recoil energy to reload the chamber, thus paving the way for semi and fully automatic weapons.18 Although many of the guns landed by the Irish Volunteers in 1914 at Howth (a small seaport on the outskirts of Dublin) were single-shot Mausers, some were of the C/96 type which was capable of holding a 10-shot magazine as was the ubiquitous Lee Enfield rifle with its .303 ammunition.19 The latter had a muzzle velocity that was at least three times faster than its mid-nineteenth-century forerunner. During the Rising, the rebels used a variety of ammunition. In his diary account of Easter Week 1916, barrister Henry Hanna mentioned that the medical examination of wounds inflicted on a number of unarmed British veteran soldiers confirmed that a variety of ordnance had been used including ‘explosive bullets & dum dum[s] which caused terrible injuries, some regulation bullets and some heavy buckshot’.20 In the decade prior to the Rising, gun ownership surged in Ireland, partly as a result of modification of the 1906 Peace Preservation Act which removed some restrictions on the purchase of firearms. Speaking at a House of Commons debate on 16 June 1910, Unionist parliamentarian Hugh Barrie condemned the ‘unrestricted traffic in the sale of rifles, guns, revolvers and ammunition to irresponsible persons’ to which fellow MP Captain James Craig added that some such weapons had found their way into the hands of children.21 Between 1912 and 1913, as a consequence of the disturbed political state of Ireland, the countrywide total for shooting and bomb occurrences reported to the police rose to 787, a marked increase over 1900 when just 246 such offences took place. Nevertheless, even these figures pale when compared with the official total for Easter Week 1916. Whereas the national total for deaths resulting from gunshot or bomb attacks in Ireland between 1912 and 1913 had amounted to just twenty-eight with a further 188 wounded, the official total for civilian

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casualties during the Rising alone was 694.22 Of those, 315 individuals were certified to have died from gunshot or bullet wounds.23 This corroborates Peter Hart’s argument that violence escalated during the revolutionary period, despite Irish murder rates being traditionally low.24 The human cost of such gun ownership (particularly on children) had first become evident during the Dublin Lockout, a widespread series of strikes that began in the autumn of 1913. That September, at a dispute in Finglas on the outskirts of the city, a boy was seriously wounded when police opened fire on a group of protesting farm labourers.25 Three months later, a 16-year-old girl was shot accidentally in the hand by a strike breaker and died of tetanus.26 In July 1914, the British Medical Journal reported that more than twenty cases of bullet wounds had been seen at Jervis Street Hospital in Dublin ‘owing to the unfortunate collision between the military and the mob’.27 After the Lockout, the shooting of children and adolescents continued to cause alarm, as emphasised by an Irish Times front page spread on 10 January 1914 which recounted the deaths of three young people, all under the age of 18.28 In January 1916, jurors attending an inquest at Temple Street Hospital heard how the future prime minister of Ireland, Sean Lemass (then a teenager), had shot his 2-year-old infant brother by accident at their Capel Street home but the jury did little more than remark that ‘something should be done to prevent young boys getting possession of firearms’.29 In both the Dublin Lockout and the Easter Rising, the shooting or bombing of children was seized upon for its propagandist value not least because it played upon contemporary fears about endangered urban youth. When an infant named Francis Foster was shot and killed at the start of Easter Week 1916, the fact that his mother’s separation allowance was thereby reduced (his father, a soldier, was missing in France) produced a public outcry. The nationalist Freeman’s Journal described it as ‘the depths of meanness’.30 The reporting of such issues tended to underscore the plight of poor, tenementdwelling children and their families connected with broader debates that had become prevalent during the Dublin Lockout. There is one caveat to bear in mind however. While it is evident that newspapers often carried reports about juvenile gunshot causalities during the revolutionary period, many belonged to society’s marginalised and were soon forgotten. To pursue their stories beyond an immediate newsworthiness, it is necessary to consult the archival papers of those who cared for them most: Dublin’s philanthropic or charitable organisations. A wartime hospital Situated in the heart of Dublin’s north inner city, Temple Street Children’s Hospital was established by the Irish Sisters of Charity in 1879. The outbreak of the First World War affected revenues and threatened to disrupt the sisters’

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Temple Street Hospital and the 1916 Rising

charitable work and with much needed aid diverted to help the war effort, they struggled to buy food, blankets, clothing and other essentials.31 Indeed, they would have found it difficult to keep the hospital open were it not for the help they received from the hospital matron, Margaret O’Flynn, who was on the committee of the Irish War Hospitals’ Supply Depot. From their premises at Lower Mount Street, Dublin, she supplied bandages, dressings and other requisites.32 By late 1914, refugees from war-torn Belgium, some of whom required medical care, had begun to arrive in Dublin via Red Cross ships.33 On 6 November 1914, the Belgian Refugees Committee wrote to the medical commissioner for the Dublin County Borough to request that they ‘supply medical assistance to Refugees in their area’. A number of the children came to Temple Street.34 Other hospitals in the city were similarly burdened, a situation made worse by a significant number of doctors having volunteered for army service overseas.35 Military medical facilities in France and Flanders were soon overwhelmed by a constant stream of casualties. By late 1914, wounded soldiers had begun to arrive in Britain and Ireland.36 The authorities were unable to cope with the influx so hotels and other large buildings were also pressed into service. In consequence of the First World War, Irish surgeons had become temporarily preoccupied with the treatment of gunshot wounds, burns and other kinds of trauma.37 The doctors at Temple Street Hospital were no exception. They included surgeons Joseph Boyd Barrett who had served with the Royal Army Medical Corps (RAMC) and John McArdle, who had operated on a bugler from the Royal Dublin Fusiliers.38 Other Temple Street doctors remained on active service with the RAMC; among them anaesthetist John Davies, dentist John Murphy and surgeon Samuel Wauchope Matthews.39 By the end of 1914, the privation had become so severe at Temple Street that O’Flynn described the war as having ‘thrown an enormous burden on the resources of the hospital’. She was quick to remind the public that ‘a large number of the children of our brave soldiers and sailors have been, and are being nursed back to health in the wards … and a still larger number receive treatment in the Extern Department’.40 The war also took its toll on staff morale. Many of the nuns had relatives fighting on the front and looked to their mother superior for consolation and support.41 Little did they realise that within a short time, the Rising in Dublin would bring war to their own doorstep. ‘An awful week of strain and terror’ By 1916, Dublin’s hospital network had been temporarily reconfigured in consequence of the war. Temple Street and its staff struggled to meet the demands of the war, but, arguably, the proximity of relief hospitals and Red Cross stations also meant that they were far better equipped to cope with the difficulties posed by the Rising than they might otherwise have been. On 24

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April 1916, Temple Street Hospital received its first casualty, an 8-year-old boy named William Cullen who arrived by horse and cart. He had been injured by a piece of stray glass when a rebel broke a window in nearby Findlater’s shop on Sackville Street.42 Another child was brought in with a bullet through the arm while trying to loot several boxes of sweets from a city centre shop. Irish MP, John Dillon, who lived near the hospital later recalled that ‘the man who brought in the child was careful to say that it was shot by a Sinn Féiner and not by the soldiers’.43 Over the following week, a total of eleven gunshot casualties were admitted. Their ages ranged from as young as 8 years old to adulthood. Initially, most were taken to a dressing station set up by the RAMC on nearby Dorset Street.44 Others were transported to an emergency Red Cross Hospital situated in an empty house on North Great George’s Street. On humanitarian grounds, its staff refused to comply with a British military directive to only admit British personnel. In many instances, agreement was reached between the rebels and the British Army that hospitals would be designated as neutral territory and that essential communication such as telephone lines should be left intact.45 However, in the case of Temple Street, visits to patients could only be obtained on the basis of a military permit and the hospital remained at constant risk from sniper fire. Of the thirteen doctors who worked there, only three lived nearby and could report for duty.46 Hospital surgeon, Charles J. MacAuley, who was forced to turn back, later recalled: Almost opposite the Mendicity Institute there was a burst of fire. We took shelter under the parapet and as we lay on the ground we saw just across the street from us a group of British soldiers firing across with rifles actually over our heads … we managed to reach Kingsbridge [train station] and we then made our way back by a circuitous route to Leeson Street.47

Fortunately, sixteen student nurses or ‘probationers’ boarded in the hospital. They remained on hand to maintain essential services.48 O’Flynn helped by converting the War Hospitals’ Supply Depot into an emergency hospital which, besides treating the casualties of Easter Week, continued to supply Temple Street with much-needed dressings.49 On Tuesday 25 April 1916, six beds were cleared in a private ward – the first floor of an old Georgian House at 13 Upper Temple Street. The house had been acquired during the 1890s and stood at a remove from the main wards, sparing other patients from witnessing the traumatic admission of the wounded adults and children. At the same time, it still allowed staff to access the kitchen, laundry and theatre without them having to leave the safe confines of the hospital. Such temporary reorganisation mirrored efforts that other hospitals had made as a consequence of the war but it is also worth assessing the extent to which this impacted on the general effectiveness of the surgical

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Temple Street Hospital and the 1916 Rising

treatment on offer. On Tuesday evening, a 19-year-old boy from Mullingar was admitted with a gunshot wound to the leg. ‘He was a fine young fellow and was badly shot’, the hospital annalist recalled, ‘he was got to bed but as he was bleeding badly, it was thought necessary to operate on him’.50 Therein lay a dilemma because the only doctor in the hospital was a house surgeon – a live-in student who, although unpaid, earned his ‘assistant’s fee’ by helping consultant surgeons in the operating theatre.51 As Martin Pernick has observed, the medical profession (internationally) faced a dilemma between the desire to reduce or eliminate suffering and the need to carry out painful surgery.52 This was a particularly prescient issue when it came to treating children and adolescents – those who society deemed to be most vulnerable and endangered. From the late nineteenth century, it was considered unacceptable to operate on conscious, albeit mechanically restrained, children who harboured ‘an expectation of something worse than what is actually felt, and generally a deficiency of resolution, that renders it impossible for them to be sufficiently quiet’.53 Thus, despite the fact that the hospital anaesthetist was unavailable, one of the nuns decided to act in his stead. At first, opiates appeared to relieve the boy’s pain. Hospital staff began to hope that he might recover but gangrene set in a few days later and his leg had to be amputated. Soldiers fighting on the front had already begun to treat their own wounds with antiseptic solutions but no consensus had been reached in Ireland about how bullet wounds ought to be treated. Some surgeons’ longheld notions about the injuries most susceptible to infection later proved incorrect. Debates abounded about the use of tincture of iodine but as Dr George Foy of Dublin noted in 1915, such ideas were ‘still on trial’.54 While this would eventually become standard practice, the innovation that came too late for gunshot victims at Temple Street.55 By the middle of Easter Week, doctors began to arrive via the adjacent laneways of Nerney’s Court and Kelly’s Row which afforded some protection from the incessant gunfire. The laneways around Hardwicke Street were subjected to a constant gunfire bombardment which battered the walls and smashed glass and woodwork into splinters.56 Hardwicke Lane was particularly hard hit with British Army gunfire damaging windows, doors and locks. The likelihood of survival at the hospital was worsened by a rapidly diminishing availability of food, including the beef tea and brandy upon which so many of the patients depended. Prior to the outbreak of hostilities, the sisters had received donations of fruit, vegetables and Easter eggs and Jacobs and Company (now held by the rebels) had even sent in ‘cake and biscuits’.57 On Friday, Charles Kavanagh, a 15-year-old boy from North King Street was admitted with a gunshot wound to the abdomen. He and his siblings had perhaps always been wayward. Five years previously, their father had been summoned to the police court for failing to keep them in school.58 Although the circumstances of his shooting are unknown, the killing of over a dozen

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people in his locality by the South Staffordshire Regiment in the area is well documented.59 A doctor arrived by one of the lanes behind the hospital to perform abdominal surgery on Kavanagh. Ian Miller has shown the increasing frequency with which such operations were performed from the 1880s. Whereas previously, intrusive abdominal surgery was usually only carried out in emergency situations or on the battlefield, this was no longer the case by the early years of the twentieth century.60 Nevertheless, in an Irish context at least, there would appear to have been some reluctance to perform such invasive procedures on children and according to FOC Meenan, abdominal surgery was rarely performed at Temple Street.61 Although Temple Street Hospital holds no contemporary theatre records, the British Medical Journal gives some indication as to how Kavanagh may have been treated. Time was of the essence. Although the hospital had contained a radiology department since 1907, the exposure time on its equipment was lengthy which meant that in order to produce a satisfactory image, the patient needed to remain completely still for several minutes making it difficult (although not impossible) to use X-rays to locate a bullet.62 In all likelihood, Kavanagh’s abdomen was opened and packed with gauze to staunch the bleeding. His loops of intestine would have been slowly disentangled and removed from the cavity. A single bullet could cause numerous holes or tears as it traversed the abdomen, each of which needed to be sutured with the attendant risk of contamination by faecal matter. In his description of an operation performed at Reigate and Redhill Hospital on a 15-year-old boy scout in 1917, Alexander Radclyffe Walters gives the following account of the procedure: ‘two mesenteric vessels were seen to be bleeding, and there were two perforations of the small intestine. The mesenteric vessels were tied.’63 Not all cases were so routine however. Edward Domville who operated on a 6-year-old boy who had been playing with a loaded rifle at the Royal Devon and Exeter Hospital in 1918 describes the scene that greeted him when he opened the abdomen: The lower part was found full of blood, which was wiped out and the pelvis packed with gauze; the coils of small intestine were then in turn taken out of the abdomen onto hot Cripps pads and the wounds in the small intestine sought for and in turn sutured; there were sixteen wounds, and from some of them portions of food and blood clot were protruding; the last hole was in the left mesocolon. The operation wound was sutured in layers and closed and the child put back to bed.64

A distinctive feature of this surgery was its use of methylated ether and a ‘tincture of iodine’ as an antiseptic measure – then quite novel but now standard when preparing a patient for theatre. Nevertheless, it was still extremely difficult to achieve surgical haemostasis and many children died on the operating table. In Kavanagh’s case, post-operatively, saline enemas with glucose were ordered every six hours and doctors watched for signs of a quickening

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Temple Street Hospital and the 1916 Rising

pulse – a sure indication that something was amiss.65 His procedure proved unsuccessful, demonstrating the relative ineffectiveness of contemporary abdominal surgery, especially in conflict zones and he joined the other deceased patients in a temporary mortuary. Their bodies were wrapped in canvas or ‘egg cases’ which, considering the warm weather would no doubt have created hygiene problems – a desperate situation that was replicated across the city. One of the priorities of the city’s Public Health Department was to protect the general public from the risk of epidemic caused by corpses left in back yards or from the decomposing remains of horses lying in the streets. It was not until several days after the rebellion had ended that the sanitary inspectors could resolve this issue.66 After a general surrender was called on Saturday, it took some time for firing to cease in the locality of Temple Street. Indeed, when a man arrived at the hospital in a horse and cart to collect the bodies, he was shot dead by a sniper’s bullet and Fr Fahy, rector of Belvedere College, had to take his place at the reins. Despite searches by the military on 1 May, sniping continued which ‘gave the military and the civil inhabitants a great deal of trouble’.67 Information about the casualties treated at Temple Street was not released until the following month and respective accounts appeared in the Irish Independent and Irish Times of 17 May. After their ‘awful week of strain and terror’, the sisters had to spend £811 on repairs to the hospital buildings – a sum which amounted to almost one-quarter of the hospital’s expenditure for the year.68 Fundraising efforts were also disrupted for a number of months as they struggled to restore a normal service against the backdrop of a war-torn city.69 Yet amid all of the destruction, the city’s doctors were at least able to learn some important medical lessons. Due to the scale of the injuries, surgeon William Pearson of Dublin’s Adelaide Hospital was able to make a special study of the effect that projectiles had on blood vessels during Easter Week. He alerted fellow medical professionals to the dangers of vascular sequelae, surgical anastomosis to repair sundered vessels and the most appropriate method of arresting haemorrhage and achieving haemostasis. One of his recommendations was that the rubber tourniquet be abandoned in favour of more modern elastic bandages which were not so likely to produce nerve damage.70 Most of the wounds seen at Temple Street Hospital in 1916 were abdominal or peripheral in nature rather than cranial. The latter simply did not survive long enough to warrant medical treatment. Those who did arrive at the hospital were very difficult to treat and the problem was compounded by their dirty condition as well as the limited availability of specialist staff. In one case, a dressing and stitching needed to be undone ‘owing to the filthy condition of the patient’.71 This challenging situation was undoubtedly mitigated through the efforts of a young convent community, many of whom had specialist training as nurses.72 It is clear from contemporary hospital records as well as from the memoirs of doctors associated with Temple Street during the revolutionary period that

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the presentation of trauma casualties sometimes required surgeons to attempt surgical procedures that were otherwise rarely performed at the hospital. This included abdominal surgery which was fraught with risk for the patient. In some instances (such as in the management of pain), children were treated differently to adults but there were limits to such considerations. Ordinarily, they did not receive visits from their families for the duration of their inpatient stay, a situation that was compounded by military cordons and curfews imposed during Easter Week. Conclusion On the first day of the Rising, three children were killed in Dublin.73 By the end of the week, civilian casualties vastly outnumbered those of the British Army or rebels.74 The precise number of gunshot casualties will perhaps remain unknown because of the confused nature of the conflict, the difficulty of keeping thorough records in a war zone and because some Dublin hospitals may have purposely withheld such information from the authorities.75 At the same time, almost 200 buildings lay ruined with at least 100,000 people left homeless or in need of relief.76 The City of Dublin Distress Committee donated 117 items of clothing to the sisters at Temple Street alone.77 The ability of the hospital to treat the casualties of the Rising, as well as to participate in the relief effort that followed, was largely made possible by the structural reorganisation of medical services in response to the First World War. Dublin’s hospital network was still orientated towards the delivery of humanitarian relief and in this way; it may be argued that the health service was proactive. Alongside this, the Rising promoted a development in surgical techniques which, besides the repair of wounded blood vessels, included the adoption of new ways of splinting fractured bones.78 Undoubtedly, the Rising presented the staff of Temple Street Hospital with many challenges but it may be argued that the old Georgian tenements had themselves always been a battlefield of sorts. Both prior to and after Easter Week, the children of the poor were wounded when they fell through broken stairwells and faulty railings or when they sustained injuries playing near railway lines, rivers and canals. ‘A child’s first steps are surrounded by danger’, the North American Review remarked, ‘[but] the physical, brutal adventure of dodging gunshot in the streets brings him nothing but crude chunks of undesired experience, more danger than he can digest’.79 Notes   1  C. Kostick and L. Collins, The Easter Rising: A Guide to Dublin in 1916 (Dublin: O’Brien Press, 2000); T. Pat Coogan, 1916: The Easter Rising (London: Phoenix, 2005); J. Dorney, The Story of the Easter Rising, 1916 (Dublin: Green Lamp Editions, 2010).

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Temple Street Hospital and the 1916 Rising   2  F. McGarry, The Rising: Easter 1916 (Oxford: Oxford University Press, 2010).   3  S. Ferguson, G. P. O. Staff in 1916: Business as Usual (Cork: Mercier Press, 2012).   4  M. O’Farrell, 1916: What the People Saw (Cork: Mercier Press, 2013).   5  A. Kinsella, ‘Medical aspects of the 1916 Rising’, Dublin Historical Record, 50:2 (autumn 1997), 137–70.   6  A. MacLellan and A. Mauger (eds), Growing Pains: Childhood Illness in Ireland, 1750– 1950 (Dublin: Irish Academic Press, 2013).   7  One exception is Ann Matthews who has compiled a list of twenty-eight gunshot fatalities under the age of 17 who were killed during Easter Week 1916 (Renegades: Irish Republican Women, 1900–1922 (Cork: Mercier Press, 2010), p. 145).   8  McGarry, The Rising; B. Kennerk, Moore Street: The Story of Dublin’s Market District (Cork: Mercier Press, 2012).   9  Margot Backus, ‘ “The children of the nation”: representations of poor children in mainstream nationalist journalism, 1882 and 1913’, in M. Luddy and James M. Smith (eds), Children, Childhood and Irish Society: 1500 to the Present (Dublin: Four Courts Press, 2014). 10  J. Dunwoody, ‘Child welfare’, in D. Fitzpatrick (ed.), Ireland and the First World War (Dublin: Lilliput Press, 1988). 11  See W. W. Keen, The Treatment of War Wounds (Philadelphia and London: W. B. Saunders, 1917); V. P. Blair, Surgery and Diseases of the Mouth and Jaws: A Practical Treatise on the Surgery and Diseases of the Mouth and Allied Subjects, 3rd edn (St Louis: C. V. Mosby, 1918). 12  R. Cooter and B. Luckin, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997). 13  Irish Times (2 December 1910), p. 5. 14  B. Kennerk, ‘In danger and distress: presentation of gunshot cases to Dublin hospitals during the height of Fenianism, 1866–1871’, Social History of Medicine, 24:3 (December 2011), 588–607. 15  J. Caird, G. Roberts, M. Farrell and D. Allcutt, ‘Self-inflicted head trauma using a captive bolt pistol: report of three cases’, British Journal of Neurosurgery, 14:4 (August 2000), 349–51. 16  D. R. Chicoine, Guns of the New West: A Close-Up Look at Modern Replica Firearms (Wisconsin: Gun Digest Books, 2005), p. 239. 17  G. St. George, ‘Case of gunshot wound of superior maxillary bones’, British Medical Journal, ii (3 December 1881), 901. 18  Anon., Firearms: An Illustrated History (London: Darling Kimberley, 2014), p. 8. 19  G. White and B. O’Shea, Irish Volunteer Soldier, 1913–23 (Oxford: Osprey Publishing, 2013), p. 62. 20  Trinity College Library (hereafter TCD) archives, MS10066/192, ‘Diary of Henry Hanna, The Sinn Féin Rising from a Suburb of Dublin: A Personal Narrative’, 1916. 21  ‘Use of Firearms (Ireland)’, House of Commons Debates (16 June 1910), vol. 17, cols 1441–2. 22  According to the Fifty-Third Annual Report of the Registrar General for Ireland of Births, Deaths and Marriages for the year 1916, the number of violent deaths registered in Ireland during that year in its various forms was 2,265. This compares with 1,955 in 1915, and an average of 1,880 for the ten years 1906–15. It may be surmised that the increase for 1916 was a consequence of hostilities. 23  Fifty-Third Annual Report of the Registrar General for Ireland of Births, Deaths and Marriages for the year 1916, Cm, 1917 [Cd.8647] p. 27. 24  P. Hart, The IRA at War, 1916–1923 (Oxford: Oxford University Press, 2003), p. 30.

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Health and political unrest 25  Freeman’s Journal (18 September 1913), p. 7. 26  Irish Times (27 December 1913), p. 4; Irish Times (10 January 1914), p. 1. 27  British Medical Journal, ii (8 August 1914), 313. 28  Irish Times (10 January 1914), p. 1. 29  Irish Independent (31 January 1916), p. 4. 30  Freeman’s Journal (17 May 1917), p. 6. 31  Irish Sisters of Charity Archive (hereafter SCA), MS419/1/2/C6, Forty-Fifth Combined Annual Report of Temple Street Hospital for the Years 1915, 1916 and 1917. 32  Army Report on the National Scheme of Co-Ordination of Voluntary Effort Resulting from the Formation of the Department of the Director-General of Voluntary Organisations, Command Papers, Reports of Commissioners, 1919 [Cmd.173] x.185. 33  M. Downes, ‘The civilian voluntary aid effort’, in D. Fitzpatrick (ed.), Ireland and the First World War (Dublin: Lilliput Press, 1998). 34  University College Dublin Archives, MS IE/UCDA, ‘Minute Book of the Belgian Refugees’ Committee’, 1914–15, p. 105. 35  P. Gatenby, ‘The Meath Hospital’, Dublin Historical Record, 58:2 (autumn 2005), 122–8. 36  British Medical Journal, ii (14 November 1914), 857. 37  This growing interest in trauma surgery was mentioned in ‘Wounded nerves and fractured femurs’, British Medical Journal, ii (8 November 1919) p. 605. The journal mentioned that 25,000 beds for the wounded were spread throughout Britain and Ireland. 38  H. W. Cattell (ed.), International Clinics: A Quarterly of Clinical Lectures and Especially Prepared Articles, Vol. 3, Eleventh series (Philadelphia and London: J. B. Lippincott, 1901), p. 264. 39  British Medical Journal, ii (7 December 1918), p. 639. 40  Temple Street Hospital Archive (hereafter TSA), Forty Second Annual Report of the Children’s Hospital, 1914. 41  K. Butler, ‘Catherine Cummins and her hospital: 1920–1938’, Dublin Historical Record, 45:2 (autumn 1992), 81–90. 42  Interview with Bill Cullen, 2 August 2012. 43  TCD, MS9820, John Dillon Papers, ‘John Dillon to Lady Mathew: An Account of the Rising’, 25 April–1 May 1916. 44  Kinsella, ‘Medical aspects of the 1916 Rising’. 45  Ibid. 46  Royal College of Physicians in Ireland (hereafter RCPI) archive, Irish Medical Directory, 1916. 47  Bureau of Military History, Witness Statement 745, Charles J. MacAuley. MacAuley later managed to reach the General Post Office where he gave medical assistance to some of the besieged rebels. 48  TSA, ‘Hospital Account Book’, 1916. 49  Army Report on the National Scheme of Co-Ordination of Voluntary Effort. 50  SCA, Annals of St. Joseph’s Hospital, 1915–1921. 51  W. A. L. MacGowan and B. O’Donnell ‘The development of surgical training in Ireland’, in B. O’Donnell (ed.), Irish Surgeons and Surgery in the Twentieth Century (Dublin: Gill & Macmillan, 2008), p. 26. 52  M. S. Pernick, A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985), p. 94. 53  Dublin Quarterly Journal of Medical Science, 32 (August and November 1861), p. 106. 54  G. Foy, ‘Letters, notes and answers’, British Medical Journal, ii (31 July 1915), 204. 55  C. Dealey, The Care of Wounds: A Guide for Nurses (Birmingham: Blackwell Publishing, 2012), p. 19.

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Temple Street Hospital and the 1916 Rising 56  Irish Independent (26 April 1916), p. 3. 57  SCA, MS419/1/2/C6, Forty-Fifth Combined Annual Report for St. Joseph’s Children’s Hospital for the Years 1915, 1916 and 1917. 58  Freeman’s Journal (6 December 1911), p. 2. 59  F. S. L. Lyons, ‘The Rising and after’, in W. E. Vaughan (ed.), A New History of Ireland Volume Five: Ireland under the Union, 1870–1921 (Oxford: Oxford University Press, 1989). 60  I. Miller, A Modern History of the Stomach: Gastric Illness, Medicine and British Society, 1800–1950 (London: Pickering & Chatto, 2011), pp. 81–106. 61  FOC Meenan, The Children’s Hospital Temple Street Centenary Book: 1872–1972 (Cahill Press: Dublin, 1973), p. 12. 62  In general, radiologists were able to produce clear images of the inner abdominal region by the outbreak of the war (see A. E. Barclay, The Stomach and Oesophagus: A Radiographic Study (Toronto: Sherratt & Hughes, 1913)), but such attempts could still be challenging in paediatric practice. A report from Devereux & Lynch, auditors and accountants to Temple Street, mentions that the length of exposure time and the need for a child to remain immobile remained problematic as late as 1930. 63  A. R. Walter, ‘Penetrating gunshot wound of the abdomen in civilian practice’, British Medical Journal, i (9 February 1918), 175. 64  E. J. Domville, ‘Gunshot wound of abdomen in a boy’, British Medical Journal, ii (30 March 1918), 371–2. 65  SCA, ‘Handwritten Account of Temple Street Hospital during the Rising’, 1916. 66  Irish Independent (8 May 1916), p. 4. 67  Sinn Féin Rebellion Handbook for Easter 1916 (Dublin: Fred Hanna, 1917), p. 30. 68  SCA, ‘Handwritten Account of Temple Street’, and TSA, ‘Kevan and Sons Auditors, Chartered Accountants: Accounts for 1916 at Temple Street Hospital’. 69  Freeman’s Journal (18 May 1916), p. 1. 70  W. Pearson, ‘Projectile injuries of blood vessels with special reference to aneurysm and the intra-saccular operation’, British Medical Journal, ii (9 December 1916), 796–9. 71  SCA, Annals of St. Joseph’s Hospital, 1915–1921. 72  K. Butler, ‘Catherine Cummins and her hospital’. 73  Matthews, Renegades, p. 146. 74  M. McNally, 1916: Birth of the Irish Republic (Oxford, Osprey Publishing, 2007), p. 91; www.glasnevintrust.ie/__uuid/55a29fab-3b24–41dd-a1d9–12d148a78f74/ Glasnevin-Trust-1916–Necrology-485.pdf. Accessed 24 March 2015. 75  Bureau of Military History, Witness Statement 735, Charles J. MacAuley. 76  S. C. Tucker, The European Powers in the First World War: An Encyclopaedia (New York: Garland Publishing, 1996), p. 365. 77  SCA, Forty-Fifth Combined Annual Report. 78  British Medical Journal, ii (8 November 1919), p. 605. 79  S. Gwynn, ‘Experience’, North American Review, 217:809 (April 1923), 502–9.

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6

Ireland’s British Army doctors and the treatment of Irish nationalists, 1916–23 David Durnin

When Britain formally entered the First World War, the Royal Army Medical Corps (RAMC), a specialist corps responsible for providing medical care to British Army personnel, immediately deployed a significant contingent of medics to accompany the British Expeditionary Force. This included 900 medical officers, 10,000 other ranked members of the RAMC and 600 military nurses. It was the largest medical contingent of any force that had left Britain.1 As the war progressed and the medical requirements of the British Army increased, the War Office augmented the RAMC with thousands of additional civilian doctors, appointed on temporary commissions for the duration of the conflict. Approximately 3,000 Irish doctors – physicians, general practitioners, medical officers and surgeons – were among this group and participated in the First World War. They joined in a well-established tradition of Irish medical participation in the British Army medical services.2 However, this chapter is not concerned with their experiences in the First World War. Instead, it examines the role of some of these men in treating the wounded in the three primary conflicts in Ireland from 1916 to 1923: the Easter Rising (April 1916), Irish War of Independence (January 1919–July 1921) and Irish Civil War (June 1922–May 1923). As part of their wartime duties within the RAMC, a contingent of Irish doctors tended to those wounded in the Easter Rising, including members of the British Army and separatist Irish nationalists. Ex-RAMC officers from Ireland also became professionally immersed in the War of Independence and the Civil War. As these wars transpired, many of the Irish doctors enlisted in the RAMC on temporary commissions for the duration of the First World War demobilised and returned to Ireland. Subsequently, some of these men provided healthcare to wounded IRA members and, later, to the Irish National Army. The Bureau of Military History witness statements, which contain approximately 1,700 first-person

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Ireland’s British Army doctors and Irish nationalists

accounts detailing the revolutionary period in Ireland from 1913 to 1921, are utilised in this chapter to explore these doctors’ diverse experiences and motives for participating in the conflicts in Ireland. These statements were provided, for the most part, by members of Sinn Féin, the Irish Republican Brotherhood, the Irish Volunteers and Cumann na mBan between 1947 and 1957. These are a somewhat problematic source. As Fearghal McGarry posits, in some cases, the witnesses have false and selective memories.3 Peter Hart has suggested that the interviews propagated a narrative that minimised republican atrocities.4 However, they are an incredibly useful collection of material that provides detailed information for the purposes of this chapter and demonstrate how those involved chose to remember their roles in the conflict as well as their interactions with members of the RAMC. Using this source, among others, this chapter will examine the complexities of the participation of Irish medics in a transitional phase of Irish history and explore how Irish Army doctors negotiated and protected their professional positions through various contexts of conflict. Easter Rising, 1916 Following the outbreak of the Easter Rising in April 1916, the RAMC was well equipped to treat those wounded in the conflict, including members of the British Army and the separatist rebels. The corps had developed a considerable medical infrastructure in Ireland to provide healthcare for wounded soldiers returning from the First World War. In conjunction with voluntary civilian hospitals and groups, such as the British Red Cross (Dublin Branch), the RAMC had established military hospitals and war wards in several Irish cities, including Dublin. Consequently, when the Rising occurred, there was an assemblage of RAMC men in Dublin. The RAMC also requested those on war leave in Ireland to mobilise. For example, during Easter Week, Dr Joseph Chaney Ridgway, who graduated from Trinity College, Dublin in 1910 and enlisted in the RAMC in 1915, was on leave in Dublin. He was staying in the Shelbourne Hotel, situated on the north side of St Stephen’s Green. On Easter Monday, a British Army officer contacted Ridgway and ordered him to report to Dublin Castle to take charge of those wounded in the Rising admitted to the large bedded ward there. At the beginning of the First World War, the Dublin Branch of the British Red Cross Society had converted part of Dublin Castle (the seat of British rule in Ireland) into a hospital for approximately 450 returning wounded soldiers.5 Medical personnel from local civilian hospitals staffed the institution. During the hostilities in Easter Week, additional RAMC medical staff, such as Ridgway, were drafted in to assist them. Throughout Easter Week and in the immediate aftermath, Ireland’s RAMC doctors treated the rebels in the Dublin Castle Hospital and at several points of conflict throughout Dublin. Notably, Lieutenant George Henry Mahony,

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an Irishman and member of the Indian Medical Services, an offshoot of the British Army medical services, provided healthcare to the rebels in the General Post Office (GPO) after they had taken him prisoner. Once he arrived in the GPO, Mahony offered his medical assistance to Jim Ryan, a 23-year-old finalyear medical student and IRB member, who had established an emergency hospital inside the building.6 Two trained nurses and several members of Cumann na mBan, an Irish republican women’s paramilitary organisation, assisted them. Mahony was not the only member of the British Army working in the GPO. The rebels generally put captured British soldiers to work and some were working in the building’s kitchen.7 McGarry has argued that in general, most prisoners were treated well and some captives helped the rebels to escape after the surrender.8 Mahony certainly had amiable relations with his captors and was instrumental in treating the rebels. Along with Ryan, Mahony treated James Connolly, one of the signatories of the proclamation and Commandant-General of the Dublin Division during the Rising. Connolly was shot in the lower leg and ankle, and suffered considerable wounds. Mahony re-set Connolly’s leg.9 Why then, did the RAMC, and Mahony in particular, treat their adversaries? Without qualitative evidence, it is only possible to speculate as to the reasons behind Mahony’s decision to assist the rebels. Perhaps it was an act of self-preservation. By offering medical care to the rebels, he endeared himself to them and ensured affable relations with his captors for the duration of his time in the GPO. Yet, it is more likely that Mahony felt professionally obliged to care for the wounded rebels. As Mark Harrison has argued, by the time of the First World War, the propaganda machines of all nations involved in the First World War sought to highlight the selflessness of their own medics, including when it came to treating their enemies.10 As such, on battlefields throughout Europe, the RAMC provided medical care to opposing forces. This was replicated in Ireland. In Dublin, the British Army doctors treated the wounded rebels who had been captured or had surrendered in the hospital wards of Dublin Castle and thus Mahony providing medical care inside the GPO was a logical extension of British Army policy. It was also his professional duty, as a doctor, to ease the suffering of those from all backgrounds and political beliefs. Throughout the First World War, medical recruitment committees had urged Irish doctors to participate in the war because it was humane and such humanity was expected given the violent nature of conflict.11 Consequently, from 1914 to 1918, members of the medical profession circulated this message, which may have further encouraged Ireland’s RAMC men to treat those wounded in the Rising. Towards the end of Easter Week, as the casualties inside the GPO mounted, Mahony was tasked with supervising the casualty evacuation process, which involved the removal of nine wounded men to the nearby Jervis Street Hospital.12 Joseph Plunkett, signatory of the 1916 Proclamation, who was in the GPO while the casualty clearing was

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organised, instructed that Mahony be allowed to leave with the casualties ‘because he had done such good work for the wounded’.13 Mahony thus oversaw the operation and his own leave from the GPO and successfully negotiated with British soldiers en route to Jervis Street Hospital to allow the wounded to complete their journey to the hospital.14 Mahony’s experiences in the GPO offer an insight into the relationship between Irish doctors in the British Army medical services and the rebels. Other incidents throughout the week provide further evidence that Ireland’s British Army doctors retained a level of professionalism when treating the wounded and, in some instances, demonstrated sympathy for the rebels. For example, Harry Colley, a member of the Irish Volunteers who served in the GPO garrison during the Rising, credited a member of the RAMC with saving his life.15 Colley was shot and severely wounded on Seán MacDermott Street, Dublin, following his attempt to charge and bayonet a British Army soldier behind a barricade. Colley fell unconscious and recalled that the next thing he remembered was a corporal of the RAMC stooping over him and saying ‘take him gently boys, he appears to be very badly hurt’. Colley has since stated that he ‘shall always remember the humane and Christian attitude of that RAMC corporal’.16 When James Grace was taken prisoner by British soldiers, an Irish RAMC officer informed Grace that the Volunteers had surrendered and that their work seemed to have been in vain as the city was in the hands of the British. Grace broke down upon hearing the news. The RAMC officer reprimanded him and told him not to let the British see how he felt. He could still serve his country by keeping a brave face.17 William Daly’s military doctor admonished him for destroying the good work that Redmond was doing but hid his bullets and other incriminating evidence.18 Similarly, during his time in Dublin Castle Hospital, J. C. Ridgway dressed the wounds of James Connolly. Ridgway recounted how twice daily he ‘dressed the wounds and had little chats with him so naturally I got attached to my patient’.19 Face-to-face encounters between British Army medical personnel and the rebels thus appear to have disrupted the propagandistic characterisations of ‘the other’ promulgated by both sides of the warring divide. The Irish War of Independence, 1919–21 Once the Rising and the subsequent executions of the leaders had finished, the RAMC men that had been involved in the emergency medical process returned to their First World War duties. However, the role of RAMC doctors in Ireland’s domestic conflicts and their dealings with Irish separatists did not conclude in 1916. Following the end of the First World War, demobilised Irish doctors returned to a tense political landscape in Ireland. The war had intensified nationalist feeling in several regions across Europe, including Ireland. In a survey of nationalist propaganda, Ben Novick posits that sections of the

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Irish public ridiculed and mocked Irish soldiers in the British Army at the start of war. Novick also argues that empathy towards soldiers was evident from the summer of 1915 to the Easter Rising but after the Sulva Bay assault at Gallipoli in August 1915, public opinion began to turn against the war, though sympathy for the Irish soldiers remained palpable.20 Yet, soldiers who returned to Ireland after the war continued to complain of receiving abuse and threats due to their association with the British Army. W. G. Fallon, Secretary of the Local War Pensions Committee Dublin, in his evidence to the Select Committee on Pensions claimed that: A reaction took place in Dublin in this sense, that these men went off amidst the enthusiasm of the public in Dublin four or five years ago. There was tremendous enthusiasm and applause and God-speeds, but in the intervening period things happened in Ireland, and when these men came back disabled and broken down in some cases they found that their own relatives had changed their views on public affairs, and matters were exceedingly uncomfortable for the unfortunate man. I do not quite know whether I ought to mention this at all, but difficulties have not yet been overcome in Ireland and are only too evident.21

In the 1980s, Jane Leonard conducted interviews with a number of Irish First World War veterans. Several recalled hostile reactions towards them when they returned to Ireland. One interviewee, Jack Campbell, recounted his time in King George V Hospital, Dublin: When I came back, I couldn’t get out of Dublin quick enough. I tell you this, I got discharged, as I told you, from the King George V Hospital on the 28th August. One evening I was in uniform. I was walking down Westmoreland Street … I noticed two ladies, well I won’t call them ladies. Two women and two men were coming towards me and when they got alongside me, the two women stepped over in front of me and spit [sic] on me. That was their way of saying they didn’t like British soldiers. They didn’t ask me if I was Irish or Dutch or what.22

Likewise, David Fitzpatrick has established that veterans, including those in the first batch of demobilised men, were intimidated by letters, subjected to assaults and their homes and work places were subject to arson attacks.23 Leonard has estimated that between the beginning of the Irish War of Independence and July 1921, the date of truce, approximately eighty-two ex-British Army soldiers were killed in Ireland.24 Eunan O’Halpin has posited that ex-servicemen constituted almost one-half of those civilians killed as spies during the War of Independence and its aftermath.25 While not victims of assassination, demobbed army doctors were fearful of being assaulted or caught in the crossfire of the War of Independence. Their worries represented broader fears shared by both ex-army doctors and those who had not participated in the conflict about working in a violent Ireland,

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despite many of them having performed benevolent work throughout the war. During the War of Independence, John Lumsden, medical officer at the Guinness Brewery in Dublin and founder of the St John’s Ambulance Brigade in Ireland, complained of the ‘difficulty and danger [doctors] experienced in carrying out their professional duties’.26 In an attempt to protect themselves, members of the medical profession arranged for the Red Cross to supply paper slips to doctors which they could attach to their cars, thereby identifying themselves as medical personnel. Lumsden hoped that the slips would allow doctors to ‘carry out their legitimate work with greater ease and … less risk and delay’.27 Several events revealed that doctors were not immune from the IRA’s intimidation tactics, and general hostility from members of the public, intensifying their fears. William Murphy has found that prison medical officers who forcibly fed nationalist prisoners were threatened at a series of public protests organised by Sinn Féin.28 Sinn Féin’s intimidation techniques included the publication of a leaflet, distributed in Limerick in February 1918, which named two MOs – Dr McGrath and Dr Irwin – which accused the doctors of engaging in a ‘British torture of Irishmen’.29 While these doctors had not participated in the First World War, returning RAMC doctors also experienced threats and verbal abuse in post-war Ireland. In 1918, Dr James Abraham, a native of Coleraine and former RAMC captain, returned to Ulster to visit his family following his demobilisation. He retained his uniform and continued to wear it after the Armistice. Upon his return to Ireland, he experienced hostile public reactions in Co. Fermanagh:30 Everyone was friendly as far as Enniskillen; but when I got out at the station at Lisnaskea, [Co. Fermanagh] a man on the platform looked at my uniform, scowled and spat on the ground. This upset me. I knew nothing much of the Casement Rising, the trouble in 1916, and the bitterness that followed; but I was now practically on the border between the warring factions, and obviously feelings were still acute. It gave me a curiously unpleasant jolt. Things were clearly very different.31

Returning army doctors were also worried that the political situation in Ireland would affect their career prospects, particularly when it came to securing state posts. By the end of the war, several boards of guardians in Ireland included members who were Sinn Féin supporters.32 When looking for a position as MO at a Tipperary dispensary district, Dr Richard Hennessy, who qualified from the National University of Ireland shortly before enlisting in the RAMC, requested that his neighbour Tom Kavanagh: Use influence with Martin and John Meagher on my behalf. Dr. Powell of Roscrea is about to resign – and I’m going for his job. I don’t think somehow the Meaghers are in my favour since I went out to France but I’d have gone just the same at that time if the Japs and Chinese were at it. Besides my work was an act of mercy. But you never know in what light some of the Guardians may look

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at it. In any case I want their [the Meaghers] support if I am to win so I shall rely on you to do all in your power for me.33

John and Martin Meagher were members of the Tipperary Board of Guardians. Martin Meagher was an avid nationalist; he was close friends with Séamus Bourke who had been elected Sinn Féin TD – member of Dáil Éireann – for mid-Tipperary in 1918.34 Hennessy’s concerns were valid. Dispensary appointments in Ireland were notoriously political and as Tom Garvin notes, patronage appointments were common.35 The IRA attempted to influence medical appointments to secure employment for their own supporters; an officer commanding the mid-Limerick brigade of the IRA tried to have one of his men appointed as visiting MO at Croom Hospital.36 Yet, the experiences of ex-British Army Irishmen were multifaceted. In multiple cases, the wartime experience gained by Irish doctors in the RAMC during the First World War made them a useful ally for the IRA. It is evident that in several instances throughout the Irish War of Independence and the Civil War, that the IRA specifically sought medical assistance from doctors who had participated in the First World War because of their experience of dealing with gunshot wounds.37 Civilian doctors who had not participated in the war often admitted that they were not au fait with the treatment of gunshot wounds. In May 1919, Dan Breen, Ned O’Brien and Jimmie Scanlon, three members of the IRA’s East Limerick Brigade, were shot and wounded while rescuing another member of their brigade from the Royal Irish Constabulary (RIC). A local doctor, William Hennessy, was sent for to treat the wounded. Hennessy arrived and, after finishing his treatment, admitted that he had ‘done his best for the wounded men but that he did not know very much about wounds’. Breen subsequently required further medical treatment from other doctors.38 While the IRA sought the medical experience of doctors who had been in the British Army medical services, their assistance was not always offered. Although some held sympathy for republicanism, others were staunchly attached to the Union and may have deplored the levels of violence being used to secure national independence. On 15 February 1921, the IRA attacked a train carrying British soldiers at Upton, Co. Cork. The train was carrying approximately fifty soldiers of the Essex Regiment. During the shoot-out on the train, two IRA volunteers were killed, one was fatally wounded and two others were badly wounded. The local dispensary doctor in Enniskean refused to attend the Brigade OC and the other wounded men. The IRA arrested the doctor, who is listed in the 1921 Medical Directory as Dr T. J. Coakley, and tried him by court-martial. They found him guilty and ordered that he leave Ireland within twenty-four hours. Coakley departed to Liverpool.39 According to the Bureau of Military History witness statements, however, it appears that these refusals were rare. Instead, there are multiple examples that indicate that demobilised British Army doctors were instrumental in

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Ireland’s British Army doctors and Irish nationalists

treating the IRA’s wounded. Harry Colley, Adjutant of the IRA Dublin Brigade, recounted that in the early months of 1920, the volunteers in his region compiled lists of friendly doctors and made arrangements with them to treat any casualties that might arise. Other brigades throughout the country made similar arrangements.40 Ex-RAMC doctors were on these friendly lists. In March 1921, the IRA ambushed British forces in Scramogue, Co. Roscommon. Marty O’Connor, a member of the North Roscommon Brigade of the IRA, was captured by the British forces and taken to Demesne House, the headquarters of the Lancers in Strokestown, Co. Roscommon. According to Patrick Mullooly, Brigade Quarter Master of the North Roscommon IRA Brigade, the Lancers tortured O’Connor in an attempt to extract information from him, beating him unconscious. Dr Dudley Forde, a former temporary RAMC captain, attended to O’Connor. Mullooly noted that Forde was ‘a good friend of the IRA’.41 Luke Duffy, member of the 3rd Battalion, South Roscommon Brigade, also noted that Forde’s services were always available to the IRA ‘on request and of course, without charge’.42 Similarly, Michael O’Cuirrin, Captain of Ring Company Irish Volunteers, recounted that Dr Edward Moynihan in Ballinagall village, who had temporarily served as a captain in the First World War, was ‘loyal to our [the Volunteer’s] cause’.43 How, then, did the IRA secure this help from the experienced doctors? On several occasions, the IRA appealed to the professional inclinations of doctors to provide care or played upon the emotional sensibilities of Irish doctors towards pain and suffering. In 1919, two junior IRA volunteers attempted to disarm two RIC officers near Drumlish, Co. Longford. The officers managed to retain their guns and shot one of the volunteers, Matt Brady, several times, shattering his leg and piercing his arm and chest.44 Seán MacEoin, IRA Brigade Director of Operations in north Longford, contacted a local doctor to treat Brady. After his examination, the doctor declared that Brady had only a short time to live because of an injury to his pericardium. Yet Brady was still alive an hour later. Consequently, MacEoin specifically sought ‘any doctor who had experience of gunshot wounds in the British Army, or who had been through the 1914–18 war’.45 Major Charles Douglas, a licentiate of the RCPI and RCSI who held a private practice in Tully House, in Killeshandra, Co. Cavan, was home on leave from military service.46 MacEoin sent volunteers to Douglas, informing him that Lord Farnham, an Irish Representative Peer who lived in the locality, had been involved in a serious motor accident and that Douglas was to come at once and bring his medical and surgical outfit with him.47 Douglas hurried. However, on the way to the ‘accident’ he began to suspect that the story was false. When he arrived at the site of the injury, MacEoin observed that Douglas ‘was highly indignant at our conduct – and I explained to him why he had been brought, that he was regarded as the only one with experience of bullet wounds … and that I now asked him, in the interest of suffering humanity, to do what he could

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for him’.48 Douglas agreed to examine Brady and arrange for a British Army ambulance to transfer him to Longford Hospital. Douglas operated on him. Ultimately, Brady survived.49 The IRA also used intimidation tactics to persuade reluctant doctors to assist, threatening to punish those who refused. William O’Hora, member of the IRA North Mayo Brigade noted how he had to find a doctor to visit a wounded member of his company. After trying three or four doctors in Ballina, he was obliged to call on a former British Army doctor. He informed the doctor about the condition of the wounded man and warned him of the consequences of revealing details of ‘what he had learned’. Faced with this threat, the doctor agreed to help and assured O’Hora ‘that professional etiquette would not permit him to divulge anything like that’.50 It is likely that doctors had a fear of recrimination if they refused. The situation with Dr Coakley in Enniskean demonstrates that there was a real possibility that the IRA could harm a doctor’s career prospects. In addition, by the early twentieth century, Ireland’s boards of guardians had become increasingly nationalist.51 These boards were responsible for appointing doctors to poor law medical posts in the dispensary districts. Therefore, failure to treat the IRA could upset republican representatives on the poor law boards and consequently harm doctors’ career prospects in Ireland. In addition, although it is hard to decisively establish that ex-British Army doctors who treated the IRA had republican tendencies, some certainly did. Thomas Myles, who had been a temporary Lieutenant Colonel in the RAMC and one of the two consulting surgeons to the RAMC in Ireland during the First World War, was a high-profile example. In August 1914, Myles had agreed to use his private yacht, the Chotah, to transport guns to Ireland for the Irish volunteers.52 Following discussions with James Creed Meredith, later President of the Supreme Court of the Irish Republic, Myles agreed to meet Conor O’Brien, leader of the Irish Volunteers in Co. Clare, on the Welsh coast and to transfer the cargo – hundreds of guns and boxes of ammunition – to Kilcoole, Co. Wicklow. From there, it was dispersed among the waiting party, which included signatories of the 1916 Proclamation of the Irish Republic, Éamon Ceannt and Seán MacDermott, as well as Cathal Brugha and Seán T. O’Kelly, a future President of Ireland.53 Myles’s gun-run coincided with the outbreak of the First World War. Upon returning to Ireland in August, Myles was called to a meeting organised by Meredith to discuss how Ireland could profit from the outbreak of the Great War. Myles was purported to have been ‘brimful of the idea that, now Ireland had her chance, as big a chance as in Grattan’s day, and that the Volunteers should take over the defence of the country and re-create Grattan’s Parliament’.54 Just a few days later, Myles accepted the position within the RAMC.55 Despite his involvement with the British Army from 1914 to 1918, Myles continued to actively support Irish separatists following the war.56 In 1919, the

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Irish Volunteers brought several of their members, wounded in skirmishes with the RIC, to the Richmond Hospital, Dublin, where Myles worked as a surgeon. The IRA transported Matt Brady to the Richmond Hospital after his wounding near Drumlish and subsequent surgery in Longford. Myles treated Brady and locked him ‘into presses and other places of concealment when the place was being searched by Black and Tans and other British forces’.57 Michael O’Dea, an Irish volunteer wounded during the Easter Rising, also recalled that he remained in hospital for three weeks under Myles’s care, whom, he said, ‘did not allow any of the wounded to fall into British hands except Edward Martin of Fianna Éireann. I do not know whether Sir Thomas was afraid lest it might afterwards be discovered that he had shielded such a well-known leader or whether he thought Martin would not recover.’58 Therefore, demobilised British Army doctors who returned to Ireland following the end of their service in the RAMC had a complex and diverse set of motivations for assisting the IRA in the Irish War of Independence. Whether encouraged to help due to feelings of professional duty, fear of recrimination, a desire to protect their career prospects, or outright support for republican ideals, Irish doctors who had served in the British Army during the First World War were an important element of the IRA’s underground medical infrastructure, established during the War of Independence. The Irish Civil War, 1922–23 While ex-RAMC doctors’ role in the War of Independence was somewhat secretive and carried out under the radar of the British Army and RIC, their involvement in the Irish Civil War was official and publicly recognised. During the interwar years, as Steven O’Connor discusses in Chapter 12 in this volume, Irish doctors continued to enlist in the RAMC. However, for those who wished to return to Ireland, there was an opportunity to continue their army work in the newly formed Irish National Army. Established in January 1922, it was the official army of the Irish Free State and operated under the control of Michael Collins, its Chief of Staff until his death in August 1922. In February, under the temporary guidance of Commandant-General Ahern, the National Army Medical Corps for the new army was established. Those who had had connections with the separatist nationalists prior to 1920 dominated the medical corps. Brigade MOs from the IRA formed a skeleton service and approximately 300 non-commissioned officers and men, without previous military experience or training, joined the corps. The medical corps also commissioned a female doctor, Dr Brigid Lyons Thornton, who had served in the Four Courts in Dublin, during the Easter Rising in 1916 and was used by Michael Collins in 1921 in an unsuccessful attempt to rescue Seán MacEoin from jail.59 Only a few men who were already in general practice enlisted, as it involved too large a financial sacrifice. Remuneration in the National Army Medical Corps was

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much lower than in general practice. Few doctors in private practice were prepared to lose income and enlist. For the most part, jobs in the medical corps appealed to newly qualified medical personnel who had struggled to secure employment elsewhere or establish profitable private practices. Following the outbreak of the Irish Civil War in June 1922, the National Army expanded in size. Ex-British Army servicemen enlisted. Leonard has estimated that approximately half of the 55,000 in the National Army were ex-British Army servicemen.60 Irish doctors who had served in the British Army also enlisted into the new medical corps. By August 1922, the National Army Medical Corps required additional personnel and expertise. The National Army sought ex-RAMC men because of their experience in the First World War. Due to the high number of casualties in Co. Cork, where the fighting was especially fierce, Ahern travelled there to take charge.61 Maurice Hayes was subsequently appointed as head of the National Army Medical Corps. Hayes had been a member of the RAMC in Ireland during the First World War and had played an important role in recruiting medical men for the British Army medical services. Tasked with increasing the number of doctors in the National Army Medical Corps, Hayes put his First World War experience to use, securing additional medical men for the National Army. He surrounded himself with ex-RAMC men. Bernard Forde, a retired lieutenant colonel from the RAMC who had served with No. 6 Clearing Hospital in France during the war, was appointed alongside Hayes to the Irish Army Medical Council. Francis Morrin, a UCD graduate and former RAMC, was appointed as surgeon and Officer in Charge at the Curragh Hospital, which was part of the National Army’s medical infrastructure and catered for a large number of its casualties. Morrin had served during the First World War in France and aboard the Mauretania hospital ship.62 By the end of 1922, eighty-five MOs and one-hundred civilian doctors were attached to the medical corps.63 At its wartime maximum, the service comprised 110 full-time MOs, 200 part-time MOs and 500 NCOs. It contained two full-time senior surgeons with a fluctuating number of junior surgeons plus two senior consultants.64 Many of these had RAMC experience from the First World War.65 In February 1923, the army introduced a new salary structure for MOs. The lower-ranked posts offered little prospect of long-term service. While ex-British Army doctors enlisted into the National Army, it was thus primarily for the duration of the Civil War. In April 1923, an article in the British Medical Journal stated that ‘it is understood that when the end of the present civil war is reached the necessity for the present comparatively large service will cease’.66 Indeed, the majority of MOs, including ex-RAMC men, demobilised from the medical corps following the end of the conflict. Subsequently, these doctors entered state posts, private practice and as O’Connor examines in Chapter 12 in this volume, others opted to re-enlist in the RAMC.

Ireland’s British Army doctors and Irish nationalists Table 6.1  Salaries for medical officers of the Irish National Army Medical Corps (1923)

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Position Lieutenant Captain Commandant Colonel Deputy Director Major-General

£

s.

d.

1 1 2 1,000 1,250 1,500

0 10 2 0 0 0

0 0 0 0 0 0

per per per per per per

day day day annum annum annum

Source: Anon., ‘Free State Army medical service’, British Medical Journal, i (1923), p. 609

Their involvement in the National Army during the Civil War demonstrates how some of Ireland’s ex-RAMC doctors reintegrated into the Irish medical profession and indeed, a complex and changing Irish society, following the end of their wartime service. Enlisting into the National Army medical corps provided these men with an opportunity to enhance, or at least re-establish, a professional identity in Ireland. In doing so, these doctors once again successfully negotiated their professional positions through the context of war. Conclusion Throughout the three major conflicts in early-twentieth century Ireland, Irish doctors who had enlisted in the British Army medical services and participated in the First World War played a significant role in the healthcare of Irish nationalists and later, members of the Irish National Army. The medical experiences garnered in the First World War made them a useful resource for the nationalist groups, such as the IRA. While this chapter has argued that the doctors’ assistance was not always offered, ultimately, it has posited that many of Ireland’s ex-British Army doctors were prepared to treat members of the IRA. Professional duty, career protectionism, and in some cases, support for the IRA’s cause, encouraged them to do so. As Byrne also finds elsewhere in this volume, ultimately, working in Ireland during periods of conflict was complex for doctors. This chapter posits that this was especially true for those who had served in the British Army during the First World War. Notes   1  M. Harrison, The Medical War: British Military Medicine in the First World War (Oxford: Oxford University Press, 2010), p. 18.   2  D. Durnin, ‘Medical Provision and the Irish Experience of the First World War, 1912–25’ (Ph.D. dissertation, University College Dublin, 2015), p. 8.

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Health and political unrest   3  F. McGarry, The Rising: Easter 1916 (Oxford: Oxford University Press, 2011), p. 4.   4  P. Hart, The IRA at War, 1916–1923 (Oxford: Oxford University Press, 2005), p. 82.   5  Thomas Myles, ‘Accommodation for Wounded Soldiers’, Irish Times (30 November 1914), p. 5.   6  J. Ryan, ‘Inside the GPO’, in F. X. Martin, L. Duffy and L. O’Briain (eds), The Easter Rising, 1916 and University College Dublin (Dublin: Browne & Nolan, 1966), p. 32.   7  McGarry, The Rising, p. 181.   8  Ibid.   9  Bureau of Military History (hereafter BMH), Witness Statement 359, Aoife de Burca, p. 14. 10  Harrison, Medical War, p. 12. 11  Anon., ‘Immediate need of doctors for the army’, British Medical Journal, ii (19 October 1918), 417. 12  BMH, Witness Statement 428, Thomas Devine, p. 8. 13  BMH, Aoife de Burca, p. 19. 14  Ibid., p. 22. 15  McGarry, The Rising, p. 177. 16  BMH, Witness Statement 1687, Harry Colley, p. 21. 17  BMH, Witness Statement 646, William Christian, p. 11. 18  McGarry, The Rising, p. 255. 19  BMH, Witness Statement 1431, J. C. Ridgway, p. 3. 20  B. Novick, Conceiving Revolution: Irish Nationalist Propaganda during the First World War (Dublin, Four Courts Press, 2001), p. 56. J. Leonard has argued that this was not unique to the First World War as there was a long-standing resentment among Irish nationalists towards Irishmen who joined the British Army in previous conflicts, including the Boer Wars (‘Getting them at last: the IRA. and ex-servicemen’, in D. Fitzpatrick (ed.), Revolution? Ireland 1917–23 (Dublin: Trinity History Workshop, 1990), p. 118). 21  First and Second Special Reports from the Select Committee on Pensions Together with the Proceedings of the Committee and Minutes of Evidence and Appendices, HC 1919 [Cd. 247] vi, p. 443. 22  J. Leonard, ‘Facing the finger of scorn: veterans’ memories of Ireland after the Great War’, in M. Evans and K. Lunn (eds), War and Memory in the Twentieth Century (Oxford: Oxford University Press, 1997), p. 59. 23  D. Fitzpatrick, Politics and Irish Life: Provincial Experience of War and Revolution (Dublin: Gill & Macmillan, 1977), p. 136. 24  Leonard, ‘Getting them at last’, p. 118. 25  E. O’Halpin, ‘Problematic killing during the War of Independence and its aftermath: civilian spies and informers’, in J. Kelly and M. A. Lyons (eds), Death and Dying in Ireland, Britain and Europe: Historical Perspectives (Kildare: Irish Academic Press, 2013), p. 332. 26  J. Lumsden, ‘Protection of Medical Men’, Irish Times (4 December 1920), p. 6. 27  Ibid., p. 6. 28  W. Murphy, Political Imprisonment and the Irish, 1912–21 (Oxford: Oxford University Press, 2014), p. 100. 29  Ibid. 30  Fermanagh had a rising republican support, which was particularly evident among young people. See P. Hart, The IRA and Its Enemies: Violence and Community in Cork, 1916–1923 (Oxford: Oxford University Press, 1998), p. 167.

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Ireland’s British Army doctors and Irish nationalists 31  J. J. Abraham, Surgeon’s Journey (London: Heinemann, 1957), p. 248. 32  See V. Crossman, Politics, Pauperism and Power in Late Nineteenth-Century Ireland (Manchester: Manchester University Press, 2006), pp. 36–70. 33  Letter from Dr Richard Hennessy, 1 June 1918, presented at the National Library of Ireland collection day organised by Europeana 1914–18, a project which brings together resources from three major European projects each dealing with different types of First World War material. www.europeana1914–1918.eu/fr/ contributions/3418. Accessed 12 March 2014. 34  Ibid. 35  T. Garvin, ‘The Dáil government and Irish local democracy, 1919–23’, in M. E. Daly (ed.), County and Town: One Hundred Years of Local Government in Ireland (Dublin: Institute of Public Administration, 2001), p. 26. 36  M. E. Daly, ‘Local appointments’, ibid., p. 48. 37  A similar situation had unfolded in nineteenth-century Ireland. Barry Kennerk has argued that army doctors who had experience in dealing with gunshot wounds from their participation in wars elsewhere treated the wounded of the Irish Republican Brotherhood as a consequence of their wartime expertise (‘In danger and distress: presentation of gunshot cases to Dublin hospitals during the height of Fenianism, 1866–71’, Social History of Medicine, 24:3 (March 2011), 588–607). 38  BMH, Witness Statement 1451, Edmund Tobin, p. 12. 39  BMH, Witness Statement 470, Denis Lordan, p. 20. 40  BMH, Witness Statement 1687, Harry Colley, p. 42. 41  BMH, Witness Statement 1086, Patrick Mullooly, p. 70. 42  BMH, Witness Statement 661, Luke Duffy, p. 27. 43  BMH, Witness Statement 1230, Michael O’Cuirrin, p. 11. 44  BMH, Witness Statement 1716, Seán MacEoin, p. 41. 45  Ibid. 46  Medical Directory, 1921, p. 1529. 47  BMH, Seán MacEoin, p. 41. 48  Ibid. 49  Ibid. 50  BMH, Witness Statement 1554, William O’Hora, p. 15. 51  Crossman, Politics, Pauperism and Power, p. 36. 52  BMH, Witness Statement 130, Seán Fitzgibbon, p. 10. 53  Ceannt and MacDermott were signatories of the Proclamation of the Irish Republic, a document issued by the Irish Volunteers and Irish Citizen Army during the 1916 Easter Rising in Ireland which proclaimed Ireland‘s independence from the United Kingdom. Brugha was the first Ceann Comhairle (chairman) of Dáil Éireann. Further details on these men can be found in J. McGuire and J. Quinn (eds), Dictionary of Irish Biography (Cambridge: Cambridge University Press, 2009), i, p. 953; ii, p. 445, v, p. 911. 54  Henry Grattan, Irish politician and campaigner for legislative freedom for the Irish parliament in the late eighteenth century. See J. Kelly, ‘Grattan, Henry’, in McGuire and Quinn (eds), Dictionary of Irish Biography, iv, p. 200; BMH, Seán Fitzgibbon, p. 11. 55  D. Murphy, ‘Myles, Sir Thomas’, in McGuire and Quinn (eds), Dictionary of Irish Biography, vi, p. 844. 56  Myles also gave evidence at the inquest of Thomas Ashe that was helpful to the protestors and very damning of the authorities’ use of forcible feeding. 57  BMH, Seán MacEoin, p. 44. 58  BMH, Witness Statement 1152, Michael O’Dea, p. 5. 59  J. Duggan, A History of the Irish Army (Dublin: Gill & Macmillan, 1991), p. 109.

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60  J. Leonard, ‘Survivors’, in J. Horne (ed.), Our War: Ireland and the Great War (Dublin: Royal Irish Academy, 2008), p. 219. 61  Outbreaks of violence were rife in Co. Cork during the Civil War. See Hart, The IRA and Its Enemies. 62  ‘Mr. F. Morrin’, Irish Times (13 July 1968), p. 8. 63  ‘How the Army Came into Being’, Freeman’s Journal (13 August 1923), p. 22. 64  Duggan, History of the Irish Army, p. 109. 65  ‘How the Army Came into Being’, p. 22. 66  ‘Free State Army medical service’, British Medical Journal, i (21 April 1923), p. 609.

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7

The ‘report of a nightmare’: hallucinating conflict in the political and personal frontiers of Ulster during the IRA border campaign of 1920–22 Fiachra Byrne

In 1940, Michael Nolan, the former medical superintendent of Down County Mental Hospital in Northern Ireland, had the last article of his long career published in the Journal of Mental Science – then the major periodical for British and Irish psychiatrists.1 Nolan had retired from his post five years earlier at the age of 75, after having been in situ for forty-two years.2 Although now an old man, he retained the intellectual strength and conviction of purpose to commit to print an account of a medical case that had fallen under his care almost two decades earlier. Evidently, something about the case appealed strongly to Nolan. It concerned a member of the infamous Ulster Special Constabulary (USC) who had become, apparently, mentally ill while serving in a Northern Irish frontier town during the early 1920s. The USC Sergeant, identified only as ‘J. M.’ or ‘John’, experienced a rather remarkable sequence of hallucinations and was subsequently committed to Down Mental Hospital under Nolan’s care. Shortly after he recovered, J. M. wrote an account of his ordeal. This narrative provided Nolan with an opportunity to voice in a textually interpolated commentary his candid opinions on psychiatry, warfare, religion and society. That he waited almost twenty years until either penning or publishing this article suggests not only his enduring sympathy for the patient but also that it raised questions he felt were difficult to address openly either in the immediate aftermath of the creation of the Northern Irish state or during his tenure as medical superintendent of a public mental hospital in that polity. The article is a ‘double narrative’ – a hybrid, doctor-patient-authored text

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– partially produced in and referring to a specific historical context of societal, sectarian conflict during the Irish Republican Army (IRA) Border Campaign of the early 1920s.3 In Nolan’s own words, it ‘reflect[ed] not only the man, but the very stirring times in which he live[d]’.4 This chapter will explore how Nolan used this narrative of individual pathology as a means to retrospectively address the social pathology underlying the sectarian conflict that then beset Northern Ireland.5 Nolan was an important figure in early twentieth-century Irish psychiatry. On the occasion of his death in 1944 his obituary writer remarked that with his passing they had lost ‘almost the last of those great figures who dominated the field of psychological medicine in Ireland’.6 He was born in 1859 into a wealthy, Catholic, mercantile family from Limerick. In 1882 he graduated from the Royal College of Surgeons in Ireland and then held a variety of hospital posts in his native city, including the Limerick District Asylum. Six years later, in 1888, he became an assistant medical officer at the Richmond District Lunatic Asylum, Dublin, working under the highly regarded psychiatrist, Conolly Norman. In 1893, he was appointed as the Resident Medical Superintendent of Down Asylum, a well-run and moderately sized hospital.7 His status among Irish psychiatrists was recognised in 1924 with his elevation to the presidency of the Royal Medico-Psychological Association (RMPA), the professional body which represented the interests of British and Irish psychiatrists.8 The ostensible medical rationale underlying Nolan’s article was to present a perfectly realised specimen of an interesting and rare disorder: a case of ‘acute systematized hallucinosis’, otherwise known as ‘sensory insanity’.9 This particular disease construct was derived from the work of the Italian professor of neuropathology and psychiatry and ‘pioneer of cerebral localisation’,10 Leonardo Bianchi.11 In Bianchi’s taxonomic system, ‘sensory insanity’ was a broad category whose distinguishing feature was the presence of hallucinations at the point of onset.12 It displaced, for Bianchi, Emil Kraepelin’s dementia praecox,13 perhaps the founding disease category of modern psychiatry as the precursor to schizophrenia, relegating it to the status of a mere syndrome within ‘sensory insanity’.14 This rejection of dementia praecox was not atypical in Italian psychiatry, or elsewhere, at the start of the twentieth century. Yet, Bianchi’s ‘sensory insanity’ gained little support outside of Italy and its adoption in a 1940 case study could suggest a degree of either intellectual antiquation or contrariness on Nolan’s part. Nolan’s somewhat grandiose case history presentation followed a tripartite structure: a prologue establishing the case’s significance and outlining his interpretative frame; a patient narrative interspersed with the psychiatrist’s social and medical commentary; and an epilogue where Nolan proposed an essentially biopsychosocial aetiology.15 The biological causal elements – including a history of syphilis, excessive use of tobacco and gastritis – were given a distinctly

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secondary billing in this treatment. The metaphors used to introduce the case in the prologue were overwhelmingly politico-military ones. The apparent rapid onset of symptoms was the ‘explosion of a magazine’ – underlying which was the ‘secret train [which had] been laid previously by a correlated chain of group factors’. These ‘group factors’ which Nolan ostentatiously described as a ‘Big Six’, outlined in a schematic presentation of medical, social and psychogenic factors in the epilogue, established what he termed ‘a revolutionary triarchy – “Religio-Sexual-Political” – the misused power of which found expression in a reign of terror’.16 The ‘overthrow of reason’, he declared, had the suddenness of a ‘coup d’état’ but after six days ‘thermidorian influences’ reasserted themselves to establish ‘normal psychic association’ and a ‘complete restoration’.17 At the end of the prologue Nolan introduced the title of the patient’s account of his attack, ‘Report of Nightmare’. Thus framed, this ‘double narrative’,18 the movement of the text between qualitatively different medical and patient perspectives, was necessarily a hierarchical form of narrative hybridisation. It entailed the framing and contextualisation by Nolan, the medical authority and specialist, of a patient-authored account. The patient’s ability to negotiate this appears to have been limited to his authorship of the illness narrative which functioned as human data for medical commentary. The ‘nightmare’ A dream is a short-lasting psychosis, and a psychosis is a long-lasting dream.19

J. M.’s narrative, the ‘nightmare’ of this story, was divided into twenty numbered sections, each of which was followed by Nolan’s commentary.20 His report related how his hallucinations began one night as he lay reading in his bunk in the RUC barracks. He suddenly began to hear ‘eight voices singing in harmony’ traditional standards such as ‘Danny Boy’, ‘Tears of an Irish Mother’, ‘Swanny’, etc. He then became afraid that the singers were ‘the Devil’s followers’, and, to protect himself, fetched a copy of the Bible and began to read some verses aloud.21 When drifting off to sleep again a figure appeared to him with a white robe and beard who reassured him. J. M. next saw a figure with black wings ‘which entirely enveloped’ him ‘and the bed, and shut out all light’.22 This figure, ‘whose breath was foul and smelling of tobacco’ demanded that J. M. surrender his copy of the bible, which he refused.23 Several men dressed in black then tortured him ‘to get possession of the Book’, placing hot bands on his body and binding his stomach with electric wire. He was later taken to a wilderness which was ‘owned by the Devil’ and endured more torture but resolved to ‘suffer death first’ rather than surrender the Bible.24 Afterwards, he was brought to a small house and ‘put into a bed in charge of three large-sized dogs’.25 Scared that he would be attacked by them, he started to read the Bible. This sequence of hallucinations ended when

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he spotted his mother in the house and she reassured him that he was now at home and safe.26 When J. M. awoke the next morning, a girl appeared to him and informed him that he had to get onto the roof of the local Young Men’s Christian Association (YMCA) to attend a ‘meeting’ for some undetermined reason. He tried this repeatedly but could not manage to get onto the roof. Nolan added that J. M. became ‘violently excited’ when he could not get onto the roof and ‘threatened to shoot anyone who attempted to take his Bible from him’.27 He was subsequently brought back to the RUC barracks where the attending physician directed him to write an account of his experiences. He did so and was then put to bed. While in bed ‘a regiment of flies [men in spirit form]’ entered the barracks and asked J. M. to join them.28 Later, he was driven to Down Asylum, which J. M. considered at first a hotel. While looking at the pictures hanging on the wall in the ward, he saw the figures within come to life and ‘kiss and hug each other’.29 He realised thereafter that the figures in the pictures were ‘human beings’ who merely ‘assumed the shape in the pictures for convenience sake’.30 Subsequently, he was pursued by his townspeople and was terrified that they were there to torture him. The voices of these pursuers – now identified as ‘evil spirits’ – insisted he ‘was to be killed that night’. Hoping to survive, J. M. resolved to put his faith in God.31 Two of the ‘spirits’ stood outside his door where they demanded that he come out ‘to face death like a man’.32 His refusal initiated another complex torture scene involving two dogs who managed to wrap a rope around his neck to choke him and used electricity to burn his skin. J. M., however, broke the rope and succeeded in defeating the spirits. After this, the spirit army of hairs, each ‘about an inch long’, returned, singing military songs; they addressed J. M. as ‘Sergeant’, asked him to come with them, and promised him the rank of ‘instructor to the battalion’ should he agree. J. M. informed them that he was presently sick but would be happy to go with them the next night at 10 p.m., to which they concurred. After the army of hairs left, another spirit army arrived – the army of cockroaches. This army wanted to take J. M. away to shoot him for the murder of their colonel. A girl who accompanied the army then spoke to J. M., informing him that though she loved him he had killed her father, the colonel, and she was thus powerless to save him and he should go with them to ‘die as a soldier should’.33 As with the army of hairs, J. M. told them that he would go with them the following night but at 9.30 p.m. rather than 10 p.m. The next morning, J. M. reported a long and complex interaction he had with the ‘Lady in the Picture’. This female figure threatened to kill J. M., claiming that he had fathered a child with her daughter and that she would take all his earnings to maintain the child. She also told him that she had told his mother of this who had ‘disowned’ him and he ‘need never go home again’.34 J. M. became distressed at this thought. That night at 9.30 p.m., the

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army of cockroaches returned ‘jubilant’ that they were to drag J. M. away to be shot. He refused and they ‘began to flock all over the bed, under the clothes and around [his] body’.35 This initiated a distressing scene where J. M. believed he was being eaten alive by the cockroach army as they ‘marched over’ his body in their thousands ‘inside [his] drawers and shirt, and … over [his] throat’. At ten o’clock the army of ‘hairs’ arrived and a battle ensued over J. M.’s body. The ‘Lady of the Picture’ exhorted J. M. to take off his shirt and shake it. J. M. followed these instructions, also striking his shirt, and the soldiers yelled at him, calling him ‘a bastard, a cowardly cur, [and] a whore’.36 The army then moved off ‘broken in body and spirit’; as they left, they called him ‘a Sinn Féiner for murdering defenceless British soldiers’.37 The following day, while J. M. was talking to the ‘Lady of the Picture’, he heard ‘a great regiment marching towards the building’. He believed that this was an army from the previous night returned in human form to kill him. The regiment stopped outside the building and informed an asylum attendant there that they had come ‘for Sergeant M.–’ whom they were to shoot ‘for the murder of eighty British soldiers’ the previous night.38 In terror, J. M. told the attendant that ‘it was against all rules and regulations of any army to take a man off a sick-bed and shoot him’.39 The medical staff sided with J. M. and refused to surrender him. The ‘Lady of the Picture’ then instructed J. M., bizarrely and unsuccessfully, on how to escape by eating flies and pushing out one of his front teeth at a 45 degree angle. This scheme having failed, some soldiers returned to his room as lizards and tried to attack him by boring through his mattress. Following this, the ‘Specials’ arrived and battled with the British soldiers outside the building. Defeated, the Specials demanded that J. M. ‘die like a soldier’ while ‘standing upon [his] own feet’ when the British soldiers came to shoot him.40 Instead the soldiers took away another prisoner to be shot while the military band which accompanied them played the ‘Dead March’. The next day, some spirit ‘girls’ got into J. M.’s bed. He could feel ‘their warm bodies’ lying next to him and they were ‘suffering with a sensual desire to have connection with’ him. He had sex with them but was ultimately unable to satisfy them ‘as they wanted connection all the time’. In order to get rid of them he squeezed their bodies until they squealed ‘out in pain’ as their backs were broken.41 Another lady in a picture, this one a queen, also got into his bed and J. M. killed her in the same way. Eventually, the original ‘Lady of the Picture’ got into bed with him as well, and he ‘crushed the life out of her and was glad’. From that point onwards, J. M. reported that the hallucinations began to decrease in frequency and intensity, drifting slowly away.42 Nolan’s commentary Nolan’s observations, fragmenting J. M.’s dream-like account, were intended to provide an objective medical perspective. The tone of his commentary was

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both assured and emphatic. As an authoritative psychopathologist and guide, he delineated the various forms of hallucinatory experience that J. M. exhibited. His exposition extended to psychiatric pedantry at times, as he pointed out instances of ‘hediphronic’ (pleasurable) alternating with ‘nociphronic’ (painful) hallucinations in pattern of ‘associations of contrast’.43 He specified in detail individual cues for hallucinatory content: J. M. heard whispering at one point ‘because of the many simultaneous sensory disturbances’ that he was experiencing;44 when he reported a sense of ‘gradual enfolding’ in his bedclothes this was explained as an instance of ‘general cutaneous hyperthesia’;45 ‘zooscopic hallucinations’ – J. M. had reported that ‘the faces of animals [had been] pressed close to [his] face – were drawn from ‘memory pictures with suitable haptic disturbance’;46 and his restlessness was attributed to ‘haptic hallucinations of spinal origin’.47 If the heuristic capacity of psychiatric concepts was inadequate to elucidate the hallucinatory scene, Nolan turned to mythology. Where J. M. spoke of eating flies as a means of escaping from his impending death, Nolan speculated that the source for this delusion may have arisen from his reading habits as a member of the Free Library. The psychiatrist invoked an ‘old charm’ contained in ‘Lady Wilde’s Ancient Legends of Ireland’ in which a black bean was placed in the mouth to turn someone invisible, ‘the associated idea being a dead fly’.48 In order to make sense of J. M.’s account of trying to push one of his front teeth out at a 45-degree angle he suggested that he may have read the story the ‘Fairy Queen of the Quicken Trees’ – from Patrick Joyce’s Old Celtic Romances – where the hero Finn mac Cool accessed his power of divination by putting ‘his thumb under the tooth of knowledge’.49 For Nolan, however, the most important psychopathological attribute of J. M.’s hallucinatory experience was its conceptual integrity. The ‘systematization of ideas’ underlying the episode was, he argued, in marked ‘contrast to typical episodes of hallucination which tend to have an incoherent flight of ideas’.50 Rather than ‘acute confusion’, he argued, ‘every incident, however strange, was accepted without question, and fitted with the plan of campaign’.51 He was also well orientated for ‘places, persons and time;’52 he exhibited a ‘mental clearness’53 and was quite of aware of his surroundings.54 Nolan attributed the underlying thematic unity of the ‘nightmare’ experience to the subjective emotion of fear which manifested itself in the range of forces which attacked J. M.55 Significantly he saw much of the hallucinatory content as deriving directly from external stimuli including paintings in the ward but also his memory and social environment. Hallucinations, war and social conflict Nolan cited with approval the words of the Viennese professor of psychiatry, Richard von Krafft-Ebing, that ‘[t]he history of hallucinations contains part of

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the history of all peoples, and of all religious opinions’.56 The Irish asylum doctor argued that this was equally true for the individual as their hallucinations might ‘contain a part, and that a very large part of the degree of civilization’ and also of religious beliefs.57 It followed that hallucinations were not meaningless epiphenomenon as they reflected both individual experience and the wider social context. This belief enabled Nolan to link the hallucinatory content of the ‘nightmare’ to aspects of J. M.’s biography, personality and social environment. To understand this aspect of Nolan’s analysis it is necessary to expand a little on the social and political context of conflict which informed it. The textual evidence indicates that the events detailed in J. M.’s narrative, ‘Report of a Nightmare’, probably took place sometime between 1921 and 1923. The town where he was resident at the onset of his attack is denoted in the text as ‘N.–’ and the only likely candidate is the Northern Irish bordertown of Newry. In the 1910s, three-quarters of the population of the town was Catholic and a nationalist majority had controlled the urban district council since 1912.58 Both the Ulster Volunteer Force (UVF) and Irish Volunteers recruited heavily from the population in and around Newry – the UVF reported that they had raised six divisions each of 150 men from six different districts in the town.59 The Home Rule crisis abated with the start of the First World War60 and significant numbers from the Irish and Ulster Volunteers joined the British Army.61 Recruitment from the rural regions of Ulster was lacklustre, particularly so in South Down,62 yet J. M., according to Nolan’s account, was a veteran of the First World War and was both ‘wounded and gassed’ in the conflict.63 Nolan’s own son, Noel, who worked as a medical officer in Hellingly Asylum in Sussex, served in the Royal Army Medical Corps during the war.64 It is unsurprising, therefore, that the imprint of the war is so apparent in Nolan’s commentary. During the scene when J. M. was taken to the desert and tortured, he reported that he ‘was crowded with soldiers and horses, and in the air there were forms flying around like angels’.65 Nolan stated unequivocally that these hallucinations were ‘war memories of infantry, cavalry and air force’.66 Likewise, he asserted that the cockroach army that infested ‘his bed, the bed-clothes and his person’ was in fact ‘a war memory of vermin in the trenches’.67 During the battle that subsequently ensued between the army of the cockroaches and the army of the hairs, J. M. described hearing ‘[c]ries of “pain” and “agony” and “murder” ’ and the ‘groans of the dying and the shouting of the triumphant’.68 Nolan opined that these auditory hallucinations were ‘in accord with the varying emotion of defeat or victory aroused by war memories’.69 When J. M. later heard ‘military music and the march of armed men’ Nolan also held that these auditory hallucinations were ‘drawn by war service’.70 This belief in the imprint of biographical experience and social context on hallucinatory content would also manifest itself in Nolan’s analysis of events in the post-war period.

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The Armistice and subsequent demobilisation released ‘fresh currents of violence into civilian life’ as ex-servicemen, often lacking alternative civic roles, indulged their abiding attraction for militarism.71 From early 1919, with the commencement of the Irish War of Independence, armed Protestant militias once again emerged72 and, to protect against ‘any attempt … to interfere with the rights and liberties of Ulster’,73 the UVF was revived.74 The conflict in the North would assume a sectarian and communal pattern of intimidation and reprisal.75 Unionist leadership disquiet at the failure of the Royal Irish Constabulary (RIC) and the British Army to contain the IRA threat, combined with the desire to establish a populist, Protestant, militant force independent of Westminster, led them to seek official endorsement and financial support for both the UVF and other militias.76 In October 1920, this was realised with the creation of the Ulster Special Constabulary (USC) which was given the imprimatur of the British government and began recruiting the following month, drawing heavily from the existing membership of the UVF.77 This Special Constabulary, of which J. M. was a member, was popularly known as the ‘B Specials’;78 it was an overwhelming Protestant force, largely sectarian in the prosecution of its duties, even ‘occasionally murderous’;79 the principle guiding recruitment was that ‘the younger and wilder the better’.80 Following the passage of the Government of Ireland Act, the establishment of partition, and the creation of Northern Ireland in 1921, the RIC was reconstituted as the Royal Ulster Constabulary (RUC) in 1922.81 By this time the number of B Specials had swelled to almost 20,000 and many of these former part-timers were mobilised for full-time duty.82 Nolan’s observation that J. M. lived ‘in a frontier town where opposing party currents foamed and raged and where he was in constant danger of violent death’,83 had some foundation in fact. The Newry Brigade of the IRA became active from around January 1920. With a notional membership of 220,84 they carried out some twenty-two attacks, resulting in nine deaths and fifteen injuries, in the Newry and South Armagh regions up to July 1921.85 In Easter 1920, the brigade was responsible for burning down Newry’s customs house,86 and in November of that year the town experienced its first fatality of the conflict with the assassination of an RIC Chief Constable.87 On 13 December 1920, a reputed force of 200 republicans attacked the RIC barracks at the nearby town of Camlough.88 In response the USC ransacked and burned out several houses in the town, targeting properties either allegedly used in the attack or belonging to Republicans.89 A sequence of attacks, ambushes and reprisals was quickly established.90 In June and July 1921 the IRA brigade was responsible for the deaths of at least three further civilians.91 The violence in Newry and its environs, however, never quite reached the scale of the Belfast riots.92 The activities of the brigade ceased for a time with the conclusion of the Irish War of Independence in July 1921. Reformed as the Fourth Northern Division and based in Louth, they recommenced their campaign in May 1922, engaging both

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the USC and the British military in several border skirmishes and, in response to the introduction of internment, kidnapping several leading Unionists and USC members from Armagh and South Down.93 On 17 June 1922 about twenty members of the division attacked a Presbyterian farming community at Altnaveigh on the outskirts of Newry, killing six, wounding many others, and bombing or burning out as many as a dozen properties.94 This attack was a reprisal for the shooting dead of two republicans by the USC and an attack on the family of a Sinn Féin counsellor, which included the sexual assault of his pregnant wife.95 This sequence of communal intimidation, murder and reprisals fomented an enduring sectarian climate of fear and anxiety.96 Nolan evidently drew upon this social context in his interpretation of J. M.’s hallucinatory ordeal as the product of a potent cocktail of ‘ReligioSexual-Political’ factors; he held that the ‘misuse’ of these three social forces was causal not only for J. M.’s ordeal but also for the ‘reign of terror’ which characterised the sectarianised border conflict of the early 1920s.97 Religion was not incidental in this ‘revolutionary triarchy’ which overthrew ‘reason’;98 and, indeed, Nolan’s own psychiatric world-view was strongly informed by his intellectual Catholicism.99 J. M.’s illness narrative had been quite clearly framed in religious terms as a battle between good and evil, and Nolan remarked upon this freely throughout his own commentary. The notion of ‘spiritual conflict’, he observed, arose out of J. M.’s own ‘religious affect’ while his ‘ego-ideal’ – a Freudian concept that conceived part of the super-ego as exhortative and idealising100 – suggested to J. M. that he would be victorious.101 The choice of the YMCA for the unrealised ‘meeting’ reflected, according to Nolan, his religious sentiments while the fact that a spirit girl had prompted the meeting suggested its sexual content. When J. M. broke free from the rope which the dogs had wrapped around his neck this was, in Nolan’s commentary, a ‘Samson-like’ liberation which ‘release[d] his exaggerated ego-ideal’ that underlay ‘the persecutory delusional content’.102 Nolan also asserted that the hallucinatory tableau of J. M.’s attempted strangulation was derived from his ‘memory picture from Proverbs’ in which the adage, ‘He is fast bound by the ropes of his sins’, provided a ‘part expression of the religio-sexual complex’.103 The nature of that complex was explained by Nolan with reference to his simultaneous relationship with two different women. One, ‘Miss A’, was Protestant and it was reported he did not wish to marry her. The other, ‘Miss B’ was Catholic and he ‘desired to marry’ her instead.104 J. M.’s parents opposed this proposed marriage and, when the two ‘girls’ had recently learned of the existence of the other, ‘a triangular quarrel followed’.105 Occupational pressures and political conflict were also significant in Nolan’s causal model. He contended that J. M.’s emergent fear of the singers who appeared at the start of his ‘nightmare’ grew from a naturally occurring ‘point of doubt’, a certain ‘[s]uspicion of motive’, that had established itself in his perspective as an occupational necessity; this was so, as doubt was ‘a feeling

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essential to the efficient performance of his official duties’ in the USC.106 Nolan, it should be remembered, felt that fear and paranoia were the central emotions governing J. M.’s hallucinations and constituted its ‘basic unity’. Later, the cockroach army that had arrived to take J. M. away to be shot for the ‘murder of their colonel’, Nolan had unambiguously identified as ‘Irregulars’, or the IRA.107 He also related a story concerning J. M. and the girl who accompanied the cockroach army, ‘Miss B’, who was the purported daughter of the colonel and who had exhorted J. M. to die ‘as a soldier should’. According to Nolan, there was a ‘possibility’ that this Miss B’s father had been in conflict with the patient during ‘the troubles’ and it is implied that he may indeed have played some role in his death.108 He argued that this repression of sexual desire for Miss B was a potent factor in precipitating J. M.’s hallucinatory episode. The texture and tenor of social terror in murderous civil conflict was evoked by Nolan when commenting on J. M.’s appeal to law when threatened with death for the murder of eighty British soldiers. He cynically remarked: ‘the patient in vain quotes “Rules and Regulations”, which, if they ever existed, were in those troubled times more honoured in the breach than in the observance’.109 Nolan emphasised the reality underlying the fear of summary execution conveyed in this hallucination in stating that ‘[t]he graphic scene of the “voices” commanding the Firing Party’ who demanded he be brought out and shot for murder ‘was drawn from the personal experience of the patient’. 110 This was further reinforced in his observation that during the ‘triangular “war” ’ of the early 1920s in Northern Ireland between ‘divided civil, and crown forces’ ‘combatants of all three parties were not infrequently taken from bed to execution’.111 This incipient societal critique crystallised in Nolan’s summation of the case when he outlined in concrete terms the causal nexus of the personal factors informing J. M.’s attack: His egoistic passions, ‘love’ or more correctly ‘lust’, ‘religion’, in the sense of adherence to a sect with an entire lack of morality which religion inculcates, ‘politics’ of the inherited type, and tending to fanaticism engendered by his upbringing, his occupation, and the stress of an acutely hostile environment.112

In Nolan’s account, J. M.’s triangular affair, his occupational hazards, his religious affect and the entire social and political context of sectarian conflict, ‘this active scene of party strife’,113 acted not only as stimuli for hallucinatory content but as a pathological cause. That conclusion was founded upon a critical appraisal of the society and culture in which this particular instance of ‘sensory insanity’ had arisen. Conclusion Nolan used J. M.’s case not only to highlight an interesting medical specimen but also as a vehicle to talk about the social and sectarian conflict that had

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afflicted Northern Ireland during the early 1920s. Using a psychiatric case to do so meant that Nolan could retain a degree of medical authority in making social judgements on the nature of a religious identity which he held was, for some, merely the expression of a sectional adherence lacking any moral basis and of a political affiliation which was a species of fanaticism. That he waited until after his own retirement until publishing the article indicates the sensitivity of broaching such views as a significant figure within the Catholic middle class in a state with a then distinctly populist Protestant political ethos. Nolan’s view of society as potentially pathological found support with the international emergence of social psychiatry after the Second World War.114 This social perspective did not necessarily imply the belief that hallucinatory and delusional content might be culturally and socially meaningful. This latter position was distinctly at odds with the psychiatric mainstream that increasingly developed in the second half of the twentieth century. Most clinicians were interested only in determining whether hallucinations or delusions were present and not in the subjective experience of these phenomena; form rather than content was significant as a medical sign.115 The psychiatrist and historian German Berrios, for instance, stated that the ‘so-called content’ of delusions and hallucinations contain ‘very little information about the world, in spite of their often bombastic claims’ and should be considered as ‘epistemologically manqué’.116 Nonetheless, Nolan in his readiness to mine such experiences for meaning finds support in more recent if contested and marginal trends.117 His focus on the social environment and his belief that hallucinations held meaning is probably partly an artefact of the insistent presence of social sectarian divisions in his own environment but it also usefully foreshadows strains within modern social psychiatry and psychology in the treatment of psychosis. Notes   1  M. J. Nolan, ‘Commentary on a case of acute systematized hallucinosis: recorded by the patient as “the report of a nightmare” ’, Journal of Mental Science, 86:364 (September 1940), 953–68.   2  R. Thompson, ‘Dr. Michael James Nolan’, Journal of Mental Science, 91:383 (April 1945), 266.   3  N. M. Theriot, ‘Negotiating illness: doctors, patients, and families in the nineteenth century’, Journal of the History of the Behavioral Sciences, 37:4 (Fall 2001), 349–68, 351.   4  Nolan, ‘Commentary’, 966.   5  Ibid.   6  Thompson, ‘Michael James Nolan’, 266.   7  Forty-Second Report of the Inspectors of Lunatics (Ireland), HC 1893–4 [C.7125] xlvi.369, pp. 107–11.   8  Thompson, ‘Dr. Michael James Nolan’, 266.   9  Nolan, ‘Commentary’, 953.   10  F. W. M., ‘Review of the mechanism of the brain and the function of the frontal lobes by Leonardo Bianchi’, Journal of Mental Science, 68:283 (October 1922), 402.

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Health and political unrest   11  L. Bianchi, A Text-Book of Psychiatry for Physicians and Students, trans. J. H. MacDonald (New York: W. Wood, 1906), pp. 704–39.   12  Ibid., p. 704.   13  Ibid., p. 723.   14  Ibid., p. 704.   15  On the biopsychosocial model, see G. L. Engel, ‘The clinical application of the biopsychosocial model’, American Journal of Psychiatry, 137:5 (May 1980), 535–44.   16  Nolan, ‘Commentary’, 953.   17  Ibid.   18  Theriot, ‘Negotiating illness’, 351.   19  Arthur Schopenhauer, quoted in L. G. Fischman, ‘Dreams, hallucinogenic drug states and schizophrenia: a psychological and biological comparison’, Schizophrenia Bulletin, 9:1 (1983), 73–94, 73.   20  Nolan, ‘Commentary’, 953–66.   21  Ibid., 954.   22  Ibid., 955.   23  Ibid., 954.   24  Ibid., 955.   25  Ibid.   26  Ibid., 956.   27  Ibid., 957.   28  Ibid.   29  Ibid.   30  Ibid.   31  Ibid.   32  Ibid., 958.   33  Ibid., 959.   34  Ibid., 960.   35  Ibid., 961.   36  Ibid., 962.   37  Ibid.   38  Ibid.   39  Ibid.   40  Ibid., 963.   41  Ibid., 964.   42  Ibid., 965–6.   43  Ibid., 955.   44  Ibid.   45  Ibid.   46  Ibid.   47  Ibid., 964.   48  Ibid.   49  Ibid.   50  Ibid., 961.   51  Ibid., 968.   52  Ibid., 956.   53  Ibid., 959.   54  Ibid., 958.   55  Ibid., 968.   56  R. von Krafft-Ebing, Textbook of Insanity: Based on Clinical Observations for Practitioners and Students of Medicine, trans. C. G. Craddock (Philadelphia: F. A. Davis Company, 1905), p. 110; Nolan, ‘Commentary’, 966.

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Hallucinations, conflict and the Civil War   57  Nolan, ‘Commentary’, 966.   58  T. Canavan, Frontier Town: An Illustrated History of Newry (Belfast: Blackstaff Press, 1989), p. 193 and p. 176.   59  Ibid., p. 179.   60  D. Fitzpatrick, ‘Militarism in Ireland, 1900–1922’, in T. Bartlett and K. Jeffery (eds), A Military History of Ireland (Cambridge: Cambridge University Press, 1997), p. 393.   61  Ibid., p. 390; Canavan, Frontier Town, p. 180.   62  T. Bowman, Irish Regiments in the Great War: Discipline and Morale (Manchester: Manchester University Press, 2006), p. 66.   63  Nolan, ‘Commentary’, 968.   64  C. O’Neill, Catholics of Consequence: Transnational Education, Social Mobility, and the Irish Catholic Elite 1850–1900 (Oxford: Oxford University Press, 2014); ‘Appointments to the R. A. M. C.’, Irish Times (28 May 1917), p. 2.   65  Nolan, ‘Commentary’, 955.   66  Ibid.   67  Ibid., 961.   68  Ibid., 962.   69  Ibid.   70  Ibid., 262.   71  Fitzpatrick, ‘Militarism in Ireland’, p. 397.   72  G. Ellison and J. Smyth, The Crowned Harp: Policing Northern Ireland (London: Pluto Press, 2000), p. 24; D. Fitzpatrick, ‘The Orange Order and the border’, Irish Historical Studies, 33:129 (May 2002), 52–67, 55–6.   73  Sir Edward Carson, quoted in Fitzpatrick, ‘Militarism in Ireland’, p. 400.   74  Ibid.   75  R. Lynch, ‘Explaining the Altnaveigh massacre’, Éire-Ireland, 45:3 (autumn 2010), 200–15, 210.   76  Ellison and Smyth, Crowned Harp, p. 25; P. Bew, P. Gibbon and H. Patterson, Northern Ireland 1921–2001: Political Forces and Social Classes (London: Serif, 2002), pp. 16–19.   77  Bew, Gibbon and Patterson, Northern Ireland, p. 19.   78  Ellison and Smyth, Crowned Harp, pp. 25–8; R. Doherty, The Thin Green Line: A History of the Royal Ulster Constabulary GC, 1922–2001 (Barnsley: Pen and Sword Military, 2004), p. 18.   79  T. Garvin, 1922: The Birth of Irish Democracy (Dublin: Gill & Macmillan, 1996), p. 112.   80  Bew, Gibbon and Patterson, Northern Ireland, p. 19.   81  Ellison and Smyth, Crowned Harp, p. 24.   82  Ibid., p. 28.   83  Nolan, ‘Commentary’, 967.   84  M. Lewis, ‘The Fourth Northern Division and the Joint-IRA Offensive, April–July 1922’, War in History, 21:3 (July 2014), 302–21, 316.   85  Ibid., 306.   86  Canavan, Frontier Town, p. 185.   87  Ibid.   88  Ibid., p. 186.   89  P. Lawlor, The Outrages, 1920–1922: The IRA and the Ulster Special Constabulary in the Border Campaign (Cork: Mercier Press, 2011), pp. 80–3.   90  Canavan, Frontier Town, p. 186.   91  Lewis, ‘Fourth Northern Division’, 306.   92  R. Lynch, ‘The people’s protectors? The Irish Republican Army and the “Belfast Pogrom”, 1920–1922’, Journal of British Studies, 47:2 (April 2008), 375–91.

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Health and political unrest   93  Lewis, ‘Fourth Northern Division’, 318.   94  Lynch, ‘Explaining the Altnaveigh massacre’, 184.   95  Lewis, ‘Fourth Northern Division’, 319; Lynch, ‘Explaining the Altnaveigh Massacre’.   96  Lynch, ‘Explaining the Altnaveigh massacre’, 194.   97  Nolan, ‘Commentary’, 953.   98  Ibid.   99  M. J. Nolan, ‘Some considerations on the present-day knowledge of psychiatry and its application to those under care in public institutions for the insane’, Journal of Mental Science, 70:291 (October 1924), 507–19, 514–15. 100  E. Zakin, ‘The “alchemy of identification”: narcissism, melancholia, femininity’, in J. Mills (ed.), Rereading Freud: Psychoanalysis through Philosophy (New York: SUNY Press, 2012), p. 91. 101  Nolan, ‘Commentary’, 954. 102  Ibid., 958. 103  Ibid. 104  Ibid. 105  Ibid., 959. 106  Ibid., 954. 107  Ibid., 959. 108  Ibid., 959–60. 109  Ibid., 962. 110  Ibid. 111  Ibid. 112  Ibid., 967. 113  Ibid. 114  N. Henckes, ‘Reforming psychiatric institutions in the mid-twentieth century: a framework for analysis’, History of Psychiatry, 22:2 (June 2011), 164–81, 172. 115  K. Jaspers, General Psychopathology, trans. J. Hoenig and M. W. Hamilton (Chicago: University of Chicago Press, 1963), p. 58. 116  G. E. Berrios, ‘Delusions as “wrong beliefs”: a conceptual history’, British Journal of Psychiatry, 159:suppl. 14 (1991), 6–13, 8 (emphasis in original). 117  M. Romme and S. Escher, Accepting Voices (London: Mind Publications, 1993).

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PART III:

Institutions and medical personnel

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8

From front to home and back again: geographical networks of auxiliary medical care in the First World War Ronan Foley Within weeks of the outbreak of the First World War, unprecedented numbers of wounded and damaged soldiers began returning to Ireland for treatment and healthcare, a movement that continued for another five or so years, up to and beyond the Armistice.1 Over the years of the war, complex geographical networks developed within both military and civilian spaces which led the wounded soldier from the Front to rehabilitation and treatment in a combination of established and auxiliary hospitals.2 This chapter contextualises these networks by mapping the locations and routes of wartime medical care, and through a discussion of typical treatment spaces on the home front in Ireland. For many Irish soldiers, this was only ever a partial journey, with almost 50,000 dying on, or behind, the front lines.3 For others, it was a repeated journey that, after treatment for a range of physical and mental illnesses and injuries, saw them return to the Front several times over.4 This chapter argues that by mapping out these networks, a new understanding of the geographical connections between home and front, especially in relation to the production of new auxiliary structures of medical care, can be developed. From muddied paths used by front-line stretcher-bearers to hospital ships bringing wounded Irish soldiers home to hospitals across the Irish Sea, the network connected specific treatment locations using a complex range of transport routes.5 In addition, the reach of the network extended well into ‘home’ or ‘civilian’ space, such that the war affected all aspects of society, during and well after its cessation.6 In mapping the routes that wounded Irish soldiers took and the different forms of transport they used, including trains, canals, steamers, ships, ambulances and horse-drawn vehicles, one can get a sense of a deeper assemblage, a mix of human and non-human components that created and sustained this therapeutic network across the war. More importantly it literally and materially brought the war home.

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As core components of the network, the specific treatment locations, referred to here as nodes, ranged from the dangerously open front-line dressing stations to large military hospitals like the 500-bed King George V Hospital in Dublin.7 Though their scales varied greatly, a key element for many nodes, such as the front-line Casualty Clearing Stations (CCS) or Base Hospitals (BH), was their essentially ephemeral and mobile nature, some being little more than wooden huts and tented compounds. This impermanency was also a feature of the more home-based nodes in the system. In light of this, this chapter also argues for a clearer articulation of the specifically auxiliary nature of such often overlooked ephemeral spaces of care. Auxiliary hospitals differed from existing military and civil hospitals used in wartime in being typically non-medical buildings that were, for the duration of the war either, borrowed, requisitioned or offered up to the war effort, to become for short periods working military hospitals or homes.8 Auxiliary hospitals were also classified as Class A, who took cot cases from military hospitals and Type B, for convalescent and ambulant cases. The treatments received in auxiliary and other military hospitals led many soldiers to recover enough to retrace their steps back to the front, a process that, for some, occurred a number of times throughout the war.9 Others ended up being invalided out of the army where skills learned during rehabilitation enabled some to get work, though the worst cases ultimately ended up being sent to asylums and other forms of institutional care.10 While the classic tropes of wartime medical care have been covered in wider media representations and additionally document individual formal medical facilities,11 they have not been considered in terms of a wider assemblage of people and places; one that had a geographical footprint that connected civil and military space in both formal and informal ways. In addition, the results of the activities within the therapeutic assemblage led to transformations of medical knowledge, during and after the war. Medical expertise gained in wartime helped develop expertise in very real and visceral emergency medicine.12 This chapter also argues that while the geography of individual medical spaces and the people in them have been documented, there is a value in mapping out a connective geography that focuses more explicitly on the mobile nature of that network, both at the front but also at home. Relational medical geographies of wartime The wider historiography of war medicine has considered in depth the high levels of mortality, the volume and range of injuries sustained in the trenches and the wider impacts on the troops and wartime society.13 Mark Harrison and others document the impact this had, particularly on the practice of wartime military medicine and tensions between medical and military priorities.14 There was a deepening of medical knowledge, especially around ‘shell shock’ (now classified as post-traumatic stress disorder), newly associated with

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the war, though with an older provenance.15 As well as mental illnesses, wholesale physical injuries and trauma led to a literal scarring of front-line troops. Large-scale facial injuries and a wide range of amputations (where not fatal) led to an increased demand for new forms of prosthetic medical surgery.16 Yet as Leo van Bergen and others argue, minor casualties and illness were as much a part of the narrative as more dramatic and documented wounds, and these were the raw material that were transported along the network and who better reflected the practice of auxiliary medical care.17 This chapter will take an explicitly geographical approach, and focus more on the spaces than the wider medical historical narratives. Within contemporary writing in historical geography, the theoretical notion of a relational geography has become increasingly popular.18 Doreen B. Massey suggests that places do not have single identities but multiple ones; are not frozen in time; are processes; and, finally, are not enclosures with a clear inside and outside. The focus instead is on the mobile and connective histories of the people and places within that space.19 In addition, the idea of assemblage has emerged as a significant theoretical idea. Assemblage as a process employs actor–network theory (ANT) and has been used in wider geopolitical terms to explore the wider connectivities of theatres of war and wartime medical treatment.20 In employing ANT at the micro level, both human and non-human actants (wood, mud, ships, steel, medical equipment, animals) merge within those historical assemblages of wartime medicine and flatten distinctions between human and nonhuman components. While the nature of the network has been well documented and its wider social meaning also discussed, its specific framing as an example of an actor–network that runs across both military and civilian space has not.21 Writing on auxiliary hospitals is motivated by a particular interest in shortlived or ephemeral health histories within what are otherwise marginal or non-medical settings. The Canadian architect Annmarie Adams has identified these as ‘borrowed buildings’, citing the specific conversion of domestic spaces into hospital and wider rehabilitative care settings in Canada.22 Specific historical studies of sites such as Brighton Pavilion, transformed between 1915 and 1916 into a hospital for wounded Indian soldiers, show how that ephemerality was organised, though this was an unusual example with wider geopolitical relevance.23 Such detailed studies are rare, as indeed are any attempts to contextualise and examine auxiliary hospitals and consider more widely ephemeral spaces of care and the processes of human and spatial transformation that such spaces experience and reflect; this chapter will attempt to add to this scholarship.24 Mapping the network Source material, especially from the Irish end of the network, is limited, in part due to Ireland’s complex post-independence relationship with Britain.25

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Key sources include the voluminous reports produced by the Red Cross and St John’s Ambulance, responsible for much of the voluntary staffing in frontline and domestic auxiliary medical facilities.26 Additional archival material is available in a number of key sources including the National Library of Ireland, National Archives (Kew), Imperial War Museum and Public Record Office of Northern Ireland.27 Online sources such as The Long Long Trail website and more recent initiatives by media outlets such as the BBC and RTÉ offer valuable photographic and personal accounts.28 The Europeana initiative, where public materials of all sorts has been collected and digitised, provides additional valuable material and insights.29 Local history libraries and archival collections have been consulted from a number of Irish counties where auxiliary hospitals were located.30 While primary and secondary source material has informed this research, a number of surviving sites have also been visited as part of more active fieldwork.31 Finally, war diaries and accounts by medical personnel, nurses and volunteers who worked along the network from Front to home provide useful glimpses into the spaces in which they worked and where they fitted in the wider assemblage.32 Individual solider/patient accounts and records are harder to find, especially for Irish soldiers, yet occasionally offer a glimpse into the different routings through the network for different types of conditions.33 In mapping the network, geographical information systems (GIS) and online digital maps such as OpenStreetMap have been used in this study to create digital point layers, showing the location of the main nodes.34 Information on specific CCS and Base Hospitals locations have been collected from a variety of sources, while various publications have provided full lists of military and auxiliary hospitals across the British Isles.35 While the routes proved more difficult to map, there was a clear sense from the locations of the different nodes on how the network connected up in space. These were very mobile geographies, as front-line medical facilities in particular, moved around during the course of the war. GIS are very effective at visualising this mobility and in storing knowledge within a database structure, though these are often hard to display in paper form. What can be mapped is the full range and extent of the network for the Western Front in which Irish soldiers were involved. This provides a sense of the spread of the network and arguably provides an effective visualising of the connectivity of the auxiliary medical care network across the spaces of the conflict. Relational geographies: networks of wartime medical care A map of the therapeutic network (Figure 8.1) shows the extent of the spaces of treatment developed and constructed from the Western Front back across the British Isles and on to Ireland throughout the war. While the locations of the different components of the network are not definitive, they do show the

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physical reach and specific components of the therapeutic assemblage. Additionally, many private homes across the British Isles provided care and rehabilitation for small numbers of soldiers, yet remain largely undocumented. Considerable numbers of wounded men of all sorts (19,255 disembarked from hospital ships in Ireland from 1914 to 1919) moved southwards, westwards and northwards via a process of hierarchical sorting, utilising a range of wood– metal–steam geographies.36 Stretchers, ambulances, ships, ambulance trains, railways and canals were identifiably non-human components of this relational geography.37 Official war histories show sketch drawings of the front-line arrangements38 a micro-scale network of dressing-stations, stretcher parties and ultimate connection to CCS and transportation to Base Hospitals and beyond.39 During the course of the war, approximately 195 CCS were located behind the front lines on the Allied side where the most significant triage type processes occurred, and where men deemed curable were moved on down the network.40 Many of these medical facilities, such as CCS No. 4, occupied ten different locations in the course of the war,41 though always retained the same name. In truth, all wars – from classical times on – have required some sort of portable front-line rapid response medical treatment facility.42 By the same token, specific locations such as Agnez-les-Duisans near Arras, hosted five different CCS at different times.43 In appearance, CCS were typically a mix of wooden huts and large substantial tents, though as the war progressed, the latter became the dominant form.44 Railway trains, ambulances and canals (the latter especially valuable because of the smoothness of the passage for badly damaged bodies), brought the wounded back to Base (or Stationary) Hospitals, a large number of which were located on the coast between Calais and Rouen (see Figure 8.1). Many were based within former resort hotels and casinos, and this auxiliary component was already in place by the autumn of 1914.45 Base Hospitals, though less mobile than CCS, also moved location during the war. Base Hospital 24 (No. 6 British Red Cross or Liverpool Merchant’s Hospital, whose patients included C. S. Lewis), moved three times between April 1915 and December 1918.46 A key node and distribution point for both healthy and wounded soldiers across the war was Étaples, where up to twenty different hospitals were spread along the coast, many in large marquee tents that opened up on one side to give a therapeutic sea view. Such was the mixing of animals and humans at Étaples; it has been putatively identified as a source location for the Spanish flu pandemic of 1918–19.47 Base Hospitals, because of their coastal settings, were also the embarkation points from which wounded soldiers and sailors were shipped back to the British Isles.48 Many wounded soldiers, especially in the early years of the war, were routed first through Netley Military Hospital on Southampton Water.49 This enormous facility, with add-on Red Cross Hospital and Military Asylum, dealt with a large number of cases, and acted as a distribution point to other civil, military and auxiliary hospitals across all four home nations. Figure 8.1 shows

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Figure 8.1  Geographical Distribution of Auxiliary Therapeutic Network in the First World War (1914–19)

the wider distribution of auxiliary hospitals across England and Wales while the Joint Committee also ran an additional network of hospitals in Scotland.50 In Ireland, around 101 different hospitals were identified as providing wartime medical care; discussed in more detail below.51 In completing the therapeutic assemblage, some even-smaller sites, like individual homes and small cottage hospitals, provided private, often unrecorded care. Not included on any of the maps were the Command Depots where wounded soldiers, once ‘cured’, were billeted prior to return to the front.52 Framing all of the above medical or recovery spaces as nodes through which the wounded or ill solider moved, helps us better articulate the geographical spread of the network. While the maps locate the nodes and, implicitly, the connecting lines of the network, the mobility of the therapeutic assemblage is harder to capture. The geography of war meant that there was a constant stream of people, moving from multiple sites of injury to multiple sites of treatment. Medical staff, from the Royal Army Medical Corps (RAMC) as well as nurses, Voluntary Aid Detachment (VADs) and the soldiers themselves, all engaged in a physical process of transportation of the wounded and ill backwards and forwards along that network. This applied at a micro-scale in the immediate vicinity of the front line and at the less reported but more macro-scale behind that, extending back to home. While not this chapter’s core concern, there was a distinctly embodied nature to that mobility as well, with a mix of formal and informal carers occupying the spaces/life of the network.53 As we shall see in the final

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section, those mobile bodies and places operated within an equally mobile therapeutic assemblage. All were subject to continuous transformations; from wounded to healed, from risk to safety, from damaged to repaired, from ignorance to knowledge; and acted as valuable empirical examples of a relational geography, in which everything was connected, yet things rarely stayed still or the same.

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Irish auxiliary hospitals as temporary treatment spaces Auxiliary hospitals functioned both as ephemeral spaces of care and as components of the wider therapeutic network. In describing the specific Irish locations as partial endpoints within the network, this reflected their contingent production as temporary medical spaces. From a fuller list of 101 Irish hospitals those of a purely auxiliary/voluntary form were much fewer, around twentyone in total.54 From the available archival information, one can piece together evidence that shows the different hospitals’ individual roles and functions within the wider assemblage.55 Figure 8.1 also shows the location of auxiliary hospitals in Ireland. The borrowed buildings drew from a range of existing functions; private homes, schools, public institutional settings and commercial spaces like hotels and hydros. While hydros already had a paramedical identity, the remainder were given a medical makeover, via the redesign and reuse of interior and exterior spaces. One of the first buildings to be offered as an auxiliary hospital was Dublin Castle, the development of which was driven by Lady Aberdeen, the Lord Lieutenant’s wife.56 The large reception rooms were ideal for hospital wards – surgical and recuperative – and immediately began to take in soldiers from hospital ships docked in Dublin Harbour.57 Separate spaces were created for officers and enlisted men. Most of the other hospitals also took in a mix of both, although the Eccles Hotel in Glengariff was made available as a recovery space in 1917 for officers only. Funding and management had a strongly voluntary tone. It was generally seen as part of the public’s role in the war effort. As such, fundraising became a wide-ranging and well-organised process.58 Aberdeen was indefatigable in this regard and many counties had a fundraising committee, which during the course of the war raised considerable funds for the operation of the hospitals.59 Even this was often not enough. The Duke of Connaught’s Hospital in Bray – developed as a specialist centre for limbless soldiers in 1916 – received a letter from Bray Town Council in 1918, who was concerned at the volume of water used in its operation, something the council was funding.60 Yet throughout the war considerable numbers of wounded and ill soldiers, around 22,000 in the south, passed through the auxiliary hospital network.61 Apart from general medical care there were specialist hospitals for limbless soldiers (in Bray and Belfast) and shell shock (Lucan and Leopardstown).62 Some

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suburban homes, such as Linden Hospital in Blackrock, retained a role as a care centre for ex-soldiers long after the war, providing a lingering trace of what was otherwise a passing historical network.63 While this chapter will pick out one case study to exemplify the general through the particular, the wider intent is to extend what has been a limited historiography which has focused more on formal hospital settings.

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Case study: International Hotel, Bray The enormous International Hotel in Bray was leased by the Joint Committees and formally opened as the HRH Princess Patricia Hospital for Wounded Soldiers on 4 August 1914 with 200 beds, 100 of which were already in use.64 It was staffed by local doctors, nurses and over 100 VADs.65 At the opening, the Lord Lieutenant noted its particular role as a convalescent and climb-down space for the general war hospitals in Dublin. As a hospital space, it had a number of advantages. Its large rooms could be easily converted into small communal wards, while the bigger dining and living spaces, also required little adaptive effort. In addition, the hotel had exterior recreational facilities and a seaside setting on a railway line, which further identified them as appropriate therapeutic spaces. It was funded to the tune of £5,000 via subscriptions, with the sponsoring agents’ names given to seven wards, such as the Co. Wicklow and Toronto.66 While the space itself required minimal transformation, its new inhabitants (dressed in the standard ‘hospital blue’ uniform), arrived with significant transformations of their own. From its foundation, a specific medical specialism developed at the hospital: the fitting of artificial limbs. Monthly Ministry of Pensions reports list, for example, that sixteen men were admitted and nineteen men discharged with fitted limbs in early April 1917.67 Indeed, Bray was one of a number of hospitals across the British Isles that performed this rehabilitative role and, along with the UVF Hospital in Belfast, were set up to relieve pressure on the original specialist hospital in Roehampton. In time, a second limbless unit, for fifty men, was set up elsewhere in Bray as the Duke of Connaught’s Auxiliary Hospital, with the International Hotel site used for convalescent purposes for soldiers discharged from the main Dublin military hospitals, like the King George V.68 The medicalisation and transformation at the site was evident in the invention of a number of experimental forms of prosthetics while the rehabilitative process involved early forms of electrical massage baths and occupational therapy such as basket-weaving. A wounded soldiers’ club on the edge of the nearby Wicklow Mountains was an additional setting for open-air therapy.69 While this vignette documents a specific example, there were a range of different processes working across all of the Irish auxiliary hospitals that provide evidence for our understanding of the wider therapeutic assemblage as mobile, contingent and ephemeral. Uncertain funding was an example of that mobility

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and contingency, as the costs rose with the demand linked to the high rate of casualties at the Front. The wider processes of fundraising, a mix of threat, volition and moral appeal, waxed and waned with feelings about the war, even more so after the Easter Rising of 1916.70 Local committees, containing a mix of grandees and local businesses, were involved in the organisation and management of auxiliary hospitals and most, given their volunteered status, were heavily dependent on private funding, such as Bloomfield House in Westmeath.71 The types of soldiers treated, by grade and condition, provide additional evidence of that mobility. At Bray, limbless soldiers moved to more appropriate and specialist facilities, or in terms of hierarchies, opened up from officers to enlisted men at a number of locations.72 Health outcomes, always complex, also shifted and changed, as some soldiers were returned to the front (a mixed blessing), some were discharged (in a variety of states) while others were invalided out or retrained for work at the end of the war. Others, echoing a lingering process of care after the war, were given pensions or were provided with residential post-war care, such as at Leopardstown Park.73 But neither soldier nor temporary medical space were left untouched by their wartime history. Discussion and conclusion: transformations of places and people This brief study of auxiliary hospitals argues that while historic healing places are generally long-standing and solid, they may also be ephemeral and flimsily functional; especially in times of urgent need, such as wartime. The nature of conflict meant that locations of medical care needed to be flexible, mobile and responsive to the relational geographies in which they were set.74 Across the First World War care environment, transformative flows took place of both bodies and practices. For those individuals that survived, at least the initial injury, variably healthy and unhealthy bodies moved backwards and forwards at different points along the therapeutic network from home to front and frequently back again.75 There was an additional flow of transformed medical learning, especially in rehabilitative medicine and mental health, experienced by both formal and informal practitioners. That transformation of medical knowledge, more intensely surgical on the front line but also evident in the auxiliary hospital networks, gave rise to significant improvements across and beyond the course of the war.76 While the development of medical knowledge on more visible illness such as shell shock or facial reconstruction continues to garner attention, progress occurred in other areas, orthopaedic, rehabilitative and minor wounds that had a more everyday flavour.77 It also occurred well away from the Front and the more active theatres of war, where the contested relations between the military and medical worlds were gentler. As a process, the production of auxiliary hospital spaces varied. Some required little or no work to convert them into functional hospitals, others

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required more effort. Converting ‘pre-medicalised’ spaces like hydros into auxiliary hospitals was a relatively simple process. St Ann’s Hill Hydro, near Blarney, had treatment rooms highly suited to the hygienic management of wounds, broken bones and soft-tissue injuries, and provided effective rehabilitative treatment.78 The reorganisation of hotels and larger private houses, distinctly non-medical prior to the war, was easier than expected, given the primarily rehabilitative role of most auxiliary hospitals. In the case of the International Hotel Bray, it was simply a case of putting additional beds in the larger bedrooms. Yet despite the limited physical transformation of the spaces, their new identities were in themselves deeply transformative, through new medicalised functions and a reorientation of their meanings and roles. In documenting a very specific impact of wartime medicine on domestic spaces, such a perspective is worthy of more detailed and specific study on new forms of therapeutic space. The transformation was equally evident in the human occupants of the auxiliary hospitals and the wider roles they assumed; many becoming experts in nursing care, retraining and rehabilitation. This applied to people already working in the buildings as well as new staff, nurses, doctors and VADs brought in to staff them.79 Deepening this process of person/place transformation was the presence of the wounded soldiers; shell-shocked in the Hermitage, amputees in Bray, or the generally ill or injured in other locations.80 In framing the hospitals as therapeutic spaces, they acted as transformed settings for transformed bodies, but in their healing dimensions, of space, care, light, quiet and rest, they in turn helped in a transformation back to health. Specific war-related injuries, especially of the mental variety, benefited from the gentle treatments and relative stillness of the ‘green/blue space’ settings of seaside, lake or wood, such as were found at Bloomfield House or St Ann’s. Sensitivity to noise and claustrophobia were observable impacts of shell shock and different auxiliary hospitals were arguably unique in providing suitable settings for the management of these symptoms. The historical contexts of the network were equally mobile through the war years. Lady Aberdeen noted the difficulties in raising money for the Dublin Castle Hospital after the Easter Rising, though the hospital itself treated the wounded from all sides, including James Connolly.81 After wide initial enthusiasm, war weariness and republicanism grew in different ways throughout the war and had a knock-on effect on how the auxiliary hospital network operated and was remembered.82 A lack of support on the ground was evident in a 1917 decision by the Lisdoonvarna Hydro Committee, who refused a request to convert it into a hospital, though shortly after hosted a visit by Eamon de Valera.83 Equally deserving of deeper analysis (though covered elsewhere in this volume) was the role of women in the network.84 There was a strong gendered element to that ‘knowledge’ transformation, both in medical and societal terms. Augusta Bellingham from Castlebellingham and Lady Desert

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from Kilkenny both ran large hospitals at respectively, Mount Stuart, Bute, Scotland and Aut Even.85 Women were central to the organisation of the Auxiliary Hospital network and to the VAD structures86 while other women, often commandeered into service within the new auxiliary hospitals spaces in which they lived and worked, developed new identities and capabilities that arguably reshaped women’s roles in the post-war world. Finally, an interest in the therapeutic assemblages of war can also consider other geographies and combatants. Each theatre of war had its own individual assemblage. Horse-drawn transports known as travoys were used to transport soldiers in the Salonika campaign, while auxiliary hospitals on Malta took in the wounded of Gallipoli.87 The Europeanea initiative is currently uncovering evidence to inform research on therapeutic assemblages in other combatant countries including France, Germany and Belgium.88 Irish research may also be usefully contrasted with parallel colonial histories, especially Canada and the well-documented role of the Anzac nations.89 In carrying out this initial exploration of the Irish networks, I would hope to encourage others, especially through what human voices exist within the archive, to uncover a deeper human understanding of those under-studied, short-lived but vital components of wider, therapeutic assemblages of wartime care. Notes   1  P. Barham, Forgotten Lunatics of the Great War (New Haven, CT: Yale University Press, 2004); M. Harrison, The Medical War: British Military Medicine in the First World War (Oxford: Oxford University Press, 2010); K. Johnston Home or Away: The Great War and the Irish Revolution (Dublin: Gill & Macmillan, 2010); E. Mayhew, Wounded: The Long Journey Home from the Great War (London: Vintage, 2014).   2  War Record of the St. John Ambulance Brigade and the British Red Cross Society in Leinster, Munster and Connaught, 1914–1918 (Dublin, 1919); Reports by the Joint War Committee and the Joint War Finance Committee of the British Red Cross Society and the Order of St. John of Jerusalem in England on Voluntary Aid rendered to the Sick and Wounded at Home and Abroad and to British Prisoners of War (London: Naval and Military Press and Imperial War Museum, 1921); P. Hoare, Spike Island: The Memory of a Military Hospital (London: Fourth Estate, 2001); T. Bowsker, The Story of British V. A. D. Work in the Great War (London: Imperial War Museum, 2003); E. Jones and S. Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War (Hove: Psychology Press, 2005).   3  As listed at the Irish National War Memorial in Islandbridge.   4  Barham, Forgotten Lunatics.   5  E. Mayhew, ‘Wounded’. www.greatwar.co.uk. Accessed 2 September 2014.   6  J. Winter, Sites of Memory, Sites of Mourning: The Great War in European Cultural History (Oxford: Oxford University Press, 2005).   7  ‘The Long Long Trail: The British Army in the Great War’. www.1914-1918.net/ wounded.htm. Accessed 28 August 2014.   8  Well-known examples include Highclere House in Hampshire, the basis for the fictional television series, Downtown Abbey and Craiglockhart Hydro in Edinburgh, immortalised in P. Barker, Regeneration Trilogy (London: Viking, 1996).

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Institutions and medical personnel   9  V. Brittain, Testament of Youth (London: Gollancz, 1993); E. Casey, The Misfit Soldier: Edward Casey’s War Story, 1914–1918 (Cork: Cork University Press, 1999). 10  Barham, Forgotten Soldiers. 11  Harrison, Medical War; Barker, Regeneration; Hoare, Spike Island. 12  Harrison, Medical War. 13  D. Fitzpatrick (ed.), Ireland and the First World War (Dublin: Lilliput Press, 1988); W. Holden, Shell Shock (London: Channel 4 Books, 1998); Harrison, Medical War. 14  R. Cooter, M. Harrison and S. Sturdy (eds), War, Medicine, and Modernity (Sutton: Phoenix Mill, 1998); L. Van Bergen, ‘The value of war for medicine: questions and considerations concerning an often endorsed proposition’, Medicine, Conflict and Survival, 23 (June 2007), 189–97; L. Van Bergen, Before My Helpless Sight (Farnham: Ashgate, 2009); Harrison, Medical War. 15  B. Shephard, A War of Nerves. Soldiers and Psychiatrists 1914–1994 (London: Pimlico, 2002); Holden, Shell Shock. Particular debates related to whether it had a physical or psychological diagnosis and to issues of morale and cowardice. 16  J. Bourke, Dismembering the Male: Men‘s Bodies, Britain and the Great War (London: Reaktion Books, 1996). 17  Van Bergen, Before my Helpless Sight; A. Carden-Coyne, The Politics of Wounds: Military Patients and Medical Power in World War One (Oxford: Oxford University Press, 2014). 18  www.history.ac.uk/makinghistory/resources/articles/historical_geography.html. Accessed 14 August 2014. 19  D. B. Massey, For Space (London: Sage, 2005). 20  S. Hysen and A. Lister, ‘British India on trial: Brighton military hospitals and the politics of Empire in World War One’, Journal of Historical Geography, 38 (January 2012), 18–34. 21  Cooter, Harrison and Sturdy, War, Medicine and Modernity; Carden-Coyne, Politics of Wounds. 22  A. Adams, ‘Borrowed buildings: Canada’s temporary hospitals during World War One’, Canadian Bulletin of Medical History, 16:1 (spring 1999), 25–48. Adams notes that during the First World War ‘the medical appropriation of buildings designed for other purposes was unprecedented’ (29). 23  The running of the hospital and treatment of wounded soldiers at Brighton was closely followed back in India (Hysen and Lister, ‘British India on trial’, 21). It also functioned as a limbless hospital after 1916. 24  C. O’Neill, ‘The Irish home front 1914–18 with particular reference to the treatment of Belgian refugees, prisoners-of-war, enemy aliens and war casualties’ (Ph.D. dissertation, Maynooth University, 2006), ch. 4. 25  K. Jeffery, Ireland and the Great War (Cambridge: Cambridge University Press, 2000); O’Neill, ‘Irish home front’, introduction. 26  Reports by the Joint War Committee; War Record of the S. J. A. 27  www.nli.ie; www.nationalarchives.ie; www.iwm.org.uk; www.proni.gov.uk. All accessed 18 July 2014. 28  The Long Long Trail. www.bbc.com/ww1; www.rte.ie/worldwar1. Accessed 14 August 2014; A. G. Butler, Official History of the Australian Army Medical Services, 1914–1918 (Canberra: Australian War Memorial, 1940). 29  The Europeana 1914–1918 Initiative. www.europeana1914–1918.eu/en. Accessed 18 September 2014. 30  Including Wicklow County and Cork City Archives and local history libraries in Westmeath, Dublin and Louth. 31  For example, visits to Bloomfield House, the remains of St Ann’s Hydro, Dublin Castle and Firmount House.

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First World War geographical networks of medical care 32  Bowsker, Story of British VAD Work; M. Borden, The Forbidden Zone (New York: Doubleday, 1930); Brittain, Testament of Youth; Siegfried Sassoon’s Diaries. cudl.lib.cam.ac.uk/collections/sassoon. Accessed 24 August 2014. 33  Casey, Misfit Soldier; Barham, Forgotten Soldiers. 34  Proprietary GIS software (ArcGIS 10.2) was used to create individual layers for different components of the network, visualised in Figure 8.1. 35  The Long Long Trail; War Record of the SJA. 36  Harrison, Medical War; O’Neill, ‘Irish home front’. 37  beyondthetrenches.co.uk. Accessed 18 September 2014. 38  wellcomelibrary.org. Accessed 4 September 2014. 39  W. G. McPherson, Medical Services of the War: General Services, Volume Two: Operations in France and Belgium, 1914–15 (London: HMSO, 1923). See also Jessica Meyer’s blog beyondthetrenches.co.uk/the-long-trip-home-medical-evacuations -from-the-front. Accessed 23 September 1914. 40  Shepherd; War of Nerves; Winter, Sites of Memory. 41  Poperinghe 1914; Lillers 1914–15; Beauval 1915–16; Varennes 1916–17; Lozinghem 1917–18; Pont Remy 1918; Pernois 1918; Colincamps 1918; Beaulencourt 1918; Solesmes 1918–19. www.1914–1918.net/ccs.htm. Accessed 4 September 2014. 42  Harrison, Medical War. 43  Five in total; CCS 7, 8, 19, 23 and 41 between 1917–19. www.1914-1918.net/ ccs.htm. Accessed 4 September 2014. 44  beyondthetrenches.co.uk 45  Mayhew, Wounded. 46  C. S. Lewis, Spirits in Bondage (London: Harcourt Brace, 1919). 47  C. Foley, The Last Irish Plague: The Great Flu Epidemic in Ireland, 1918–19 (Dublin: Irish Academic Press, 2011). Close mixing of animals and humans has also been identified as a causal factor in contemporary flu pandemics. 48  Mayhew, Wounded. 49  Hoare, Spike Island; Barham, Forgotten Soldiers. 50  Reports by the Joint War Committee, p. 716. 51  Ibid; The Long Long Trail. 52  In Ireland, Ballyvonare near Buttevant was one such site. 53  Carden-Coyne, Politics of Wounds. 54  Reports by the Joint War Committee, p. 716. 55  O’Neill, ‘Irish home front’, appendix 4, for the full list. The three largest were at Bray, Dublin Castle and the Irish Counties War Hospital, Glasnevin. 56  Lord and Lady Aberdeen, ‘We Twa’, in Reminiscences (Glasgow: W. Collins, 1925). 57  Ibid., pp. 238–43. 58  O’Neill, ‘Irish home front’, pp. 135–40. 59  Reports by the Joint War Committee lists individual county committee heads while Lady Aberdeen noted the Red Cross raised £8,153 for the operation of the Dublin Castle Hospital. 60  County Wicklow Archives, ‘Letter dated 31 March 1918’. 61  O’Neill, ‘Irish home front’, appendix 4. 62  J. Bourke, ‘Shell-shock, psychiatry and the Irish soldier’, in A. Gregory and S. Pašeta (eds), Ireland and the Great War: A War to Unite Us All? (Manchester: Manchester University Press, 2002). 63  O’Neill, ‘Irish home front’. 64  Reports by the Joint War Committee; Irish Times (4 August 1915), p. 7. 65  Irish Times (4 August 1915), p. 7; O’Neill, ‘Irish home front’, ch. 4. 66  O’Neill, ‘Irish home front’, ch. 4.

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Institutions and medical personnel 67  Kew, CAB/24/4/9, Ministry of Pensions, ‘Report for Period from the 31st of March to 6th of April, 1917’. 68  Reports by the Joint War Committee. 69  B. White, ‘The Shamrock Fund in World War One’. Lecture delivered to Clondalkin History Society, 20 March 2014. 70  O’Neill, ‘Irish home front’, ch. 5. 71  ‘Report of the A. G. M. of the Bloomfield Red Cross Auxiliary Hospital’, Westmeath Examiner (24 August 1918), p. 1. 72  Examples included St Ann’s Hydro. 73  Leopardstown Park Hospital Newsletter, 31:8 (July 2011), p. 14. 74  M. Goniewicz, ‘Effect of military conflicts on the formation of emergency medical services systems worldwide’, Academic Emergency Medicine, 20:5 (May 2013), 507–13. 75  Several sources site the co-location of CCS and post-war cemeteries. See Winter, Sites of Memory, introduction. 76  Mayhew, Wounded; Harrison, Medical War. 77  Harrison, Medical War, p. 99. 78  S. O’Leary, ‘St. Ann’s Hydro, Old Blarney’, Journal of the Blarney and District Historical Society, 5:3 (Millennium Edition 2000), pp. 1–31. 79  Nine surgical staff and five GPs operated at the International Hotel under the supervision of Lieutenant-Colonel Lyell of the RAMC; Irish Times (4 August 1915), p. 7. 80  O’Neill, ‘Irish home front’, ch. 4, lists 267 men treated at the International Hotel before its move elsewhere. 81  Aberdeen, Reminiscences, p. 239. 82  O’Neill, ‘Irish home front’, ch. 6. 83  M. Dooley-Shannon, ‘The historical development of tourism in Clare: portrait of a spa town: Lisdoonvarna, 1800–1914’ (master’s dissertation, University of Limerick, 1998), p. 101. 84  E. Reilly, ‘Women and voluntary war work’, in Gregory and Pašeta (eds), Ireland and the Great War. 85  National Library of Scotland, H8/96/722, Marchioness of Bute, ‘Description of Mount Stuart as a Hospital, 1914–19’. Unpublished manuscript, 1923. 86  Bowsker, Story of British VAD Work. 87  Harrison, Medical War, chs 4 and 6; P. Orr, Field of Bones: An Irish Division at Gallipoli (Dublin, Lilliput Press, 2006); www.bbc.co.uk/guides/zpx8d2p. Accessed 15 November 2014. 88  Europeanea 1914–18. 89  Ibid.; www.awm.gov.au; ww100.govt.nz.

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9

Hope and experience: nurses from Belfast hospitals in the First World War Seán Graffin

Nursing the wounded during the First World War was, borrowing a phrase from Samuel Johnson, the triumph of hope over experience. This chapter explores the background of nurses from Belfast hospitals and their wartime roles. It adopts a multifaceted approach in order to unearth the fragmented history of nurses who worked in wartime Belfast. It is important to define what is meant by ‘nurses from Belfast hospitals’. To fully encompass the term, this chapter analyses nurses who fulfilled the following criteria: 1  nurses who had trained in a Belfast hospital and remained employed there during the war; 2  nurses who had trained in a Belfast hospital and volunteered for military nursing service during the war; 3  nurses who worked in a Belfast hospital during wartime after being trained elsewhere. It commences with an investigation of the professionalisation of Irish nursing and the pre-war organisation of nursing services in anticipation of conflict. It then asks: which type of individual volunteered for nursing? What social backgrounds did they hail from? What motivated them to enlist? A subsequent section examines the various institutions in place in Belfast that employed nurses during wartime, identifying the commonalities and differences in institutional approaches to caring for war casualties. It examines issues such as wartime nursing shortages, the responses of Belfast hospitals to such problems and the (often frustrating) experiences of nurses who remained employed on the domestic front rather than overseas. There is a dearth of primary material relating to nurses who worked in Belfast hospitals during the war. In contrast, a relative wealth of sources exists

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relating to those who joined a military nursing organisation. This imbalance is reflected in the subject matter of this chapter. The main sources for the military nursing organisations are the Nurses’ Service Files held at the National Archives, Kew. The files chart the nurses’ full service history including date and place of birth, training prior to the war and regular confidential reports with assessment of their performance. The records also contain routine dayto-day correspondence and ephemera dealing with bureaucratic elements of the nurses’ lives. Many of the records contain documentation which can be used to provide a skeleton framework of the background of individual nurses’ anguish. Much has been written about nursing and its reformation from a dubious, disorderly occupation in the early nineteenth century into a modern, skilled profession by the early twentieth century. The image of Sarah Gamp has been depicted as the model of the archetypal nurse in the 1840s and 1850s. However, Anne Summers has argued that this was a caricature of a type of nurse ‘who worked largely as independent practitioners in the homes of their patients’.1 This type of unregulated domiciliary nursing was at variance with what was happening in hospitals.2 The rise of the voluntary hospital in Britain and Ireland and its changing role throughout the course of the nineteenth century had a major influence in the development of nursing. The role of the nurse changed from 1860 onwards as hospitals took control of the nurses that they employed. The hospitals regulated their nurses in such a way that, according to Bashford, a ‘new’ type of nurse emerged who created a practice that resulted in ‘increased order, regulation, accountability, and basic cleaning’.3 At the heart of this reform of nursing was the principle of discipline. Bashford has written that ‘the concepts and practices of “discipline” and “training” link the modernisation of nursing and hospitals with both religious and military discourse’.4 These two elements have been seen as key factors as to how civilian nurses could adapt so readily to army nursing. As nurses became more self-aware of their nascent professional status there began a campaign for self-government by means of a system of state registration of nursing which would establish it as a legitimate profession. The key elements in this campaign were the right of nurses ‘to determine the standard and duration of nurse education, to control entry into the ranks of nurses, and to improve their pay and conditions’.5 This campaign began in 1888 and only came to fruition with the Nurse Registration Act in 1919. The highly publicised part that nurses played in the war helped to bring this about. There has been a growing number of studies into nursing and nurses’ participation during 1914 and 1918. Most of these have taken a general approach to nursing and the First World War by looking at how allied professional nursing was organised,6 the history of British Army nursing during the war7 or as part of a wider medical discourse.8 This chapter attempts to adopt a more focused examination by presenting an interesting case study of an Irish

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Nurses from Belfast hospitals in the First World War

city, its hospitals and the range of roles which their nurses performed during the course of the First World War. Belfast provides a thought-provoking example with regard to its hospitals and nurses as it exhibits both similarities and disparities with other Irish and British cities at the time. While many of the nursing features might not be unique to Belfast there are, however, unusual aspects as to how nursing was organised within the political context of the period. The city of Belfast provides an intriguing case study. However, it does not fit neatly within the context of an archetypal Irish city. Belfast was the only truly industrialised city on the island of Ireland. By the end of the nineteenth century, it had grown from an insignificant port to become a major industrial powerhouse.9 This transformation had resulted from the Industrial Revolution. The growth of Belfast and its prosperity resulted in an influx of people from the Ulster countryside looking for better-paid work than was available in the rural economy. The subsequent rise in population fed the expansion of the city. The census of 1901 shows that the city’s population had risen to just under 350,000. Belfast at that time was larger than Dublin and wealthier.10 Belfast has always had more in common with cities in Britain than with those in Ireland. Its industrialised character meant that it shared more parallels with Glasgow and Liverpool than with Dublin and Cork. Consequently, it developed along a different path from Dublin. Due to the changing religious make-up of the city during the nineteenth century, sectarianism was always palpable. Riots occurred frequently due to religious intolerance. Again, this showed similarities to Glasgow and Liverpool where an Irish Catholic presence was evident. The proportion of Catholics in Belfast dropped in the latter half of the century. By 1901, Catholics only composed about 25 per cent of the city’s population.11 In contrast to Dublin and other Irish cities, by 1914 Belfast was able to adapt its vigorous industrial power towards the war effort. All of the city’s major industries were in great demand to meet the needs of Britain in time of conflict. Nursing, training and war In Belfast, as elsewhere, nursing had changed throughout the course of the nineteenth century. The image of the Sarah Gamp type of nurse in the first half of the century reflected the way in which society viewed nursing.12 Women who pursued nursing careers were from the lower classes; uneducated and untrained they were looked upon as mere servants whose work consisted of very basic care. Moreover, nurses were typically denigrated as unhygienic, immoral individuals whose presence posed a threat to professional medical practice. With the rise and development of the voluntary hospital system in Britain and Ireland, the need for a ‘new’ type of nurse became obvious. Nurses had to be more than just domestic servants due to the growth of medical

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expertise in relation to diseases and their treatment. Their role was changing in order to assist the doctor in caring more effectively for patients with complex illnesses and injuries.13 Throughout much of the nineteenth century, no formal systematic training provision was available for nurses at the Belfast General Hospital, the forerunner of the Royal Victoria Hospital. This situation was similar to most other European countries. In 1861, the Board of Management discussed the issue of formal nurse training for the hospital.14 However, it was only in 1870 that the Board once again proposed a scheme to establish a nurse training school within the hospital.15 Similar developments occurred in other Irish cities. By 1878, the City of Dublin Hospital had nine trained nurses on its staff. In 1883 the Board of Directors announced the establishment of the City of Dublin Nursing Institution ‘for training women as nurses for the sick in hospitals and in private families’.16 The training was for one year at first. In 1890, examinations were introduced before awarding a certificate. By 1900, training had been raised to two years.17 With the grand opening of the new Royal Victoria Hospital on the Grosvenor Road in 1903, probationer nurses were able to be systematically trained in the most state-of-the-art settings. During their training, nurses worked on a variety of medical and surgical wards for several weeks at a time to acquire comprehensive experience in all aspects of nursing care. The new Royal Victoria Hospital provided much greater integration of probationer nurses into the hospital system, since they were paid both by the hospital and under control of the Matron Miss Mary F. Bostock. Military nursing had been a relatively unimportant aspect of war until the inadequate nature of care for wounded soldiers became evident in the Second Boer War.18 Hallett argues that the Second Boer War (1899–1902) had a fundamental effect on how military nursing evolved in Britain. This was a dual development. First, the Boer War was the first conflict in which a large force of volunteer soldiers was used to supplement the regular army. Subsequently, thousands of men died from disease as well as injury. The result was a demand for reform within the army to provide better services for treating ill and injured soldiers. Second, the deployment of a large number of civilian nurses and medics into the war zone made the inadequacies of contemporary military medical and nursing services potently clear.19 Soldiers from Belfast had also participated in this war. Six nurses who trained in the Royal Victoria Hospital worked in South Africa during the Second Boer War.20 One of these, Sister Lavinia Badger, also saw service in the First World War. The utilisation of nurses in the First World War was unparalleled due to the sheer scale of the conflict. Military officials recognised that the army required a significant number of nurses to deal adequately with the physical and psychological consequences of total war. Preparing to care for casualties en masse was a hugely complex undertaking. This circumstance presented a challenge for medical and nursing services on both the British and Irish

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Nurses from Belfast hospitals in the First World War

domestic fronts; the recruitment, organisation and mobilisation of thousands of nurses needed to be implemented to an unprecedented extent. At the onset of war, Britain had three core military nursing organisations. The Queen Alexandra’s Imperial Military Nursing Service was established in 1902. As a reserve to be called into action only in the event of conflict, the Queen Alexandra’s Imperial Military Nursing Service Reserve formed in 1908. In the same year, the Territorial Force Nursing Service was created as a secondary reserve of trained civilian nurses who could be called up to serve in British and Irish hospitals housing casualties of war.21 In the weeks that followed the declaration of war, applications for the military nursing services increased rapidly. The War Office was compelled to issue a warning to hospital nurses in October stating that no one had any authority to approach hospital nurses or nursing institutions with a view to securing their services in France. If a nurse was approached, they should contact the War Office, the British Red Cross or the St John Ambulance Association.22 Evidently, at the start of the First World War, Belfast (similarly to other industrial cities) had a professionalised corps of trained nurses who provided an ample pool of potential recruits for wartime nursing organisations. Motivations Many trained Protestant and Catholic nurses from Belfast hospitals volunteered for military nursing service during the war.23 Their service records provide some insight into their motivations for undertaking military nursing. David Fitzpatrick has questioned the motives of Irish men who signed up for military service in the war noting that, in the absence of coercion, every man’s decision was personal and voluntary.24 This argument is also applicable to Belfast nurses. There are, however, several common motivating factors which encouraged whole contingents of nurses into military service. For example, although evidence is sparse, it seems highly probable that many nurses enlisted out of a deeply held patriotic fervour for King and Country. Mary Best, for example, who had completed her training in the Royal Victoria Hospital in 1913, noted that her decision to become a military nurse was strongly influenced by seeing parties of soldiers frequently marching through the streets throughout July 1914. Writing in the early 1950s, she recalled: ‘As I had always been attracted by the notion of army nursing, these martial sights and sounds were too much for me. I applied at once to join the Q. A.s.’25 She applied on 5 August 1914.26 Other nurses enrolled to escape a tedious way of life, seeking adventure and excitement in foreign climes. Many Belfast-trained nurses had rural backgrounds, their fathers being small farmers. They saw wartime nursing as a means of breaking away from a life of drudgery on the farm and acquiring some measure of independence. War offered these women a unique opportunity to see the world. Many certainly did. Ellen Agnes Boyle, was the daughter

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of a farmer from Co. Roscommon, who trained in the Belfast Union Infirmary from 1906 to 1909. She enlisted in the Service Reserve in September 1915, at the relatively mature age of 37. During the war, she found herself posted in hospitals in Basra, Mesopotamia and India. Fitzpatrick has also argued that loyalty to friends and families, apart from a desire for adventure and subsidised international tourism, provided a key driving factor for Irish military recruitment.27 He notes that this was a natural progression for those recruits who already belonged to some sort of social organisation or paramilitary group such as the Ulster Volunteer Force (UVF). Unlike many men in the north of Ireland, long hours and heavy workloads precluded many women from joining a social club or actively partaking in the rapidly shifting politics of the day. It seems plausible that nurses developed a strong loyalty to the hospital in which they trained or worked and established long-standing friendships with other nurses with whom they worked and lived in the hospital. Many of those who joined the military nursing service did so along with their friends. A number of nurses completed their applications for military service at the same time. In the Belfast Union Infirmary no fewer than four nurses applied for service in the first week of September 1915: Ellen Agnes Boyle, Mary Erwin, Sara Jane Williams Houston and Elsie Christina Lister. Some of these women saw military nursing as more desirable than civilian hospital work, not least because of better pay and higher promotion prospects. Nurses’ pay in civilian hospitals varied depending on the post and hospital size. For example, the Royal Victoria Hospital paid staff nurses £25 per annum. Sisters received £36 per annum in addition to board and lodgings.28 The Belfast Union Infirmary in 1913 paid charge nurses between £26 and £30 per annum.29 Nursing pay in the military service clearly compared favourably with civilian rates. The scale of pay in the Queen’s Alexandria Imperial Military Nursing Service and Territorial Force Nursing Service in autumn 1916 was high. The Services paid staff nurses £40 per annum with an annual increment of £2 and 10s. up to a maximum of £45 per annum. Nurses were awarded a £20 bonus after one year’s service if they agreed to sign an undertaking to remain in service until no longer required. Nurses also had a uniform allowance of £8 per annum with all expenses paid, including travel. A Sister would start at £50 per annum with an annual increment of £5 up to a maximum of £65 pounds per annum. She also received a £20 bonus upon completing one year’s service.30 Evidently, wartime nursing offered Irish women opportunities to escape the tedium of agricultural life, see distant parts of the world and, importantly, offered attractive pay and promotion packages. But how did Belfast-based nurses experience war? Their role varied depending on factors including age, training and experience. Good character and moral conduct were important elements in the decision as to where nurses would work. Those who received orders to travel could be faced with the

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Nurses from Belfast hospitals in the First World War

challenge of working in a number of different geographical climates. Some found themselves dispatched to distant locations including Serbia, Egypt, India and East Africa; many undertook service in France and Belgium where they worked on ambulance trains, hospital ships and the extensive hospital system that had been constructed around the battlefields. A large proportion of nurses found themselves dispatched to the medical network established across western Europe. Despite initial concerns by military medical officers regarding the suitability of allowing young women to be sent close to the front lines, many Belfast-based nurses were posted to casualty clearing stations to work as part of a small surgical team in place to treat serious wounds and injuries. At these, nurses gained considerable experience in assisting surgeons.31 They helped medical staff to perform operations by dressing wounds and upholding hygiene to prevent infection. A case in point is Sister Agnes MacMahon, who was born in Belfast and trained in the Union Infirmary. She volunteered for the Queen Alexandra’s Service and was called up in early 1915. She served for a year as sister-in-charge of the surgical division and operating theatre at Lichfield Military Hospital before being sent to France. There she worked tirelessly in Casualty Clearing Stations and had the dubious distinction of being on duty in two separate stations when they were bombed. She also worked in Arras after the battle in Easter 1917. Following this, MacMahon was posted to a hospital near Étaples, an area that suffered from numerous air raids that killed many patients and staff. She was awarded the Royal Red Cross in 1919.32 Many nurses worked in hospitals constructed at military bases on the northern French coast to accommodate wounded soldiers in transit from the front line. Their patients often suffered from severe trauma and required a long recuperation period before being deemed fit enough to return home or back to the front. These relatively large establishments required a high number of nurses to function.33 An example of the variety of work some nurses experienced in military nursing during the war is provided by Mary Best who had trained in the Royal Victoria Hospital. She joined the Queen’s Alexandra Service in 1914. Over the next four years she worked in a range of settings. She was initially sent to Cork Military Hospital which, according to her ‘was so out of the way that few wounded were sent there’.34 In October 1915 she ‘was one of a party of Q.As deposited at Boulogne, and was posted with two other Irish sisters to the 14th Stationary Hospital, formerly the Grand Hotel at Wimereux’.35 Here she spent most of her time nursing typhoid cases. Following a fire in the typhoid ward/hut in January 1916 she was posted to the 14th General Hospital. On learning that nurses were required for hospital ships, she recalls that ‘I put down my name for the new experience although I was quite happy at the 14th General.’36 Towards the end of 1916 she was appointed to HMS St David and crossed the Channel over 120 times. Her next assignment was on ambulance trains running from Southampton to

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various hospitals in Britain. By October 1917 she again volunteered for hospital ship work in the Mediterranean and was assigned to HMS Wandilla where she worked for the next ten months. The ship had to remain in dock at the port of Alexandria for a month and Mary Best, along with the other nurses, worked in the local hospitals. While many nurses may have been attracted to the prospects of overseas employment, great demand existed for their services on the Irish home front throughout the war. Civilian patients still required care. In addition, the system of territorial hospitals was established for the evacuated required nurses. Belfast hospitals formed an important part of this system. Some military nurses found such work boring and tedious and wished to work in France or further afield. Indeed, many nurses frequently requested overseas employment. Belfast-trained nurse, Violet Jolly, provides an example of the sheer frustration and anguish that some wartime nurses experienced. Jolly was born in Liverpool in 1887 and trained in the Royal Victoria Hospital between September 1910 and January 1914. She joined the nursing service in November 1914. For the next four years, Jolly was deployed to several military hospitals in Ireland and England. In April 1916, she was promoted to the rank of Sister and sent to No. 1 War Hospital, Birmingham where she remained until March 1919.37 Jolly’s wartime career was limited to caring for the wounded on the home front. This proved to be a tedious and dispiriting experience as she watched her friends being posted to France and beyond. In October 1917, she wrote to the War Office requesting a transfer to France where she could have joined a friend who had been working there since 1915. Jolly was placed on a waiting list. A year later, in a fit of desperation, she contravened military regulations by taking the unprecedented step of writing directly to the matron-in-chief of the Queen Alexandra Imperial Military Nursing Service to request transfer abroad. Her letter was poignant; revealing much about Jolly’s innermost emotions and how wartime realities had affected her at a very personal level. In the letter she described her hopelessness after the recent death of her fiancé in action. She begged to be moved from the home front hospital so she could be of better use overseas. She emphasised her lack of family; explaining that she felt alone in the world and was willing to take the place of a nurse who had a family to mourn her. She wrote: A short time ago I received news that my fiancé had been killed but nobody at the hospital knew and I do not wish it known – there are things that one cannot bear discussed – they are too sacred. But now there is nothing left for me to live for. My parents, my brothers, and now Jack all gone. So I wonder if you could give me something to do on a Hospital Ship and if there is a [illegible] going to Russia if you would allow me to join it – I might go in place of some Sister who would have parents to mourn her loss if anything happened to her – while my decease would affect no person and I am only too anxious to give my life for my country if need be. I am spending my leave at my Guardian’s home and return

Nurses from Belfast hospitals in the First World War

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to duty on the 15th inst. at the 1st Birmingham War Hospital. The monotony of my four years Home Service has been broken by periodical ‘leaves from France’ but now that is all over and I long to do something ‘worthwhile’ – something he would have been proud of.

The brief letter is touching in the matter-of-fact way in which Jolly described her personal experience and her aspirations to achieve something meaningful with her life. Jolly never got her wish as the war ended in the following month.38 Given that many nurses seem likely to have been attracted to the prospects of overseas work, it is unsurprising that those who remained in Belfast could experience a deep sense of frustration. What is clear is that Belfast-based nurses played an important role in the medical network that formed around the trenches and ultimately stretched back as far as relatively distant locations including the north of Ireland. This network, discussed in more depth by Ronan Foley in Chapter 8 in this volume, structured the wartime experiences of nurses – even in relatively peripheral places to the theatre of war such as Belfast – and had important implications for those employed within the hospital. Belfast sites of care What institutional conditions did nurses who remained in Belfast work in? What problems did they encounter? And how did they experience hospital work? At the outbreak of war, Belfast had three major civilian hospitals. The Royal Victoria Hospital had reopened on new premises in 1903. The Belfast Union Infirmary (part of the Belfast Workhouse) had significantly expanded from its foundation in the 1880s. The Mater Infirmorum Hospital had been established in 1883 by the Sisters of Mercy. There was also a number of smaller specialised hospitals scattered across the city. In addition, a military hospital was in place in the precincts of Victoria Barracks in the north of the city. An organisation named the Belfast Incorporated Nurses’ Home consisted of trained nurses who delivered private nursing to those who could afford it. Following the call to help, another institution – the Ulster Volunteer Force Hospital – was established in the city. Looking at each of these institutions we can identify the commonalities and the differences in their approach to the care of war casualties. The Royal Victoria Hospital was the oldest and most prestigious hospital in the city. Founded in 1792 as the Belfast General Hospital, it grew throughout the nineteenth century to become Belfast’s principal medical establishment. In 1903, the hospital moved from its old premises in Frederick Street to a modern purpose-built building on Grosvenor Road. When the news of war reached Belfast, the hospital began to prepare for the potential influx of military

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casualties. Its management prepared two wards to receive soldiers and reserved a further fifty-four beds in other unused wards specifically for casualties.39 In August 1914 the hospital offered a total of 100 beds for wounded sailors or soldiers. Half of these were intended to be immediately available and the remainder at twenty-four hours’ notice.40 The hospital had a large number of nursing staff on its books as well as a constant supply of probationers. A large number of the hospital’s staff volunteered for military service in 1914. While this departure was not on the same scale as other hospitals, it made a significant impact on the institution. Due to a shortage of personnel, the nurses who remained had to work longer hours. More than thirty nurses who trained or worked in the Victoria Hospital enlisted in the military nursing organisations. When the first wave of wounded soldiers arrived in Belfast in November 1914, Belfast-based nurses encountered wounds inflicted in a war setting for the first time.41 Throughout the nineteenth and early twentieth centuries, the Royal Victoria Hospital had treated many patients who had been the victims of sporadic sectarian violence in the city. Serious riots in 1857 and 1886 had resulted in casualties being taken to the hospital for medical treatment. Hospital staff had also treated numerous gunshot victims over the years. Nonetheless, they were more accustomed to treating victims of accidents, fever patients and individuals afflicted with diseases associated with poverty. The accidents involved mainly industrial incidents in the linen factories the shipyard and other manufacturing businesses in industrialised Belfast. From 1914, nursing staff had to adjust to caring for a new kind of patient: young men harmed in military conflict. Colonel Andrew Fullerton (who had spent over three years in the Royal Army Medical Corps) alluded to the diverse wartime experiences of Royal Victoria Hospital nurses when he spoke at the Royal Victoria Hospital annual meeting held in March 1919. He paid tribute to the medical and nursing staff of the hospital, declaring that ‘the nurses in hospitals, clearing stations, on trains, and ships had done magnificent work, and Miss Bostock [the matron] and the hospital had good reason to be proud of them’. He also reported that ‘in one clearing station during the early part of the final push last year, I came across three of their nurses, all in responsible positions and all very favourably reported on’.42 Between 1914 and 1918, 1,209 soldiers and 171 sailors had been cared for in the Royal Victoria Hospital.43 The Belfast Union Infirmary was established in 1875 as part of the Belfast Workhouse complex. In 1903, further wings were added to the building to provide more wards. The hospital management formally introduced nurse training in the Union Infirmary in 1888.44 Suffering similar problems as the Royal Victoria Hospital, in the weekly meeting of the Belfast Board of Guardians on 13 October 1914, it transpired that Union Workhouse officers had volunteered for service including a charge nurse.45 In response to a sudden

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Nurses from Belfast hospitals in the First World War

shortage of trained nurses, the Belfast Union advertised for fifteen probationer nurses, aged between 21 and 33, to take up training with them.46 Nonetheless, nurses trained at the Infirmary continued to depart from Belfast, once again pointing to the relative attractiveness of overseas wartime work. By January 1916, the Board of Guardians reported that there were no fewer than 120 nurses who had trained at the Union Infirmary on active service in the various theatres of war.47 Belfast Union created a specific military hospital for sick soldiers within its grounds. By the end of 1914, the military had taken over this building which continued to cater for wounded soldiers for almost two years with assistance from nurses employed at the Infirmary. However, the use of the union infirmaries was discontinued in 1916. Resident military patients were transferred to the UVF Hospital and the Military Hospital in Victoria Barracks.48 This step caused great resentment within the Infirmary. The Military Hospital at Victoria Barracks cared for ill or wounded soldiers based at the barracks. During the war, Mary Anne Flynn served as matron; a Catholic from Co. Cavan. She had trained in the London Hospital, Whitechapel before being posted to King George V Military Hospital, Dublin, in August 1914. This hospital was a specialist neurological unit for cases identified in other hospitals in Ireland (rather than having been processed through the clearing system). She was soon posted to Belfast as sister-in-charge. Within a short period she was appointed hospital matron.49 In August 1917, a medical board found Flynn to be suffering from debility which was characterised by severe insomnia and frequent headaches. They ascribed the cause of her illness to the effects of constant overwork; a scenario that provides further evidence of the mental strain placed on Belfast-based nurses during the First World War compounded by often sparse staffing conditions and the psychological pressure of caring for wounded soldiers. Flynn took a six-week sick leave. It appears that, following her sick leave, she was posted to No. 71 General Hospital in October 1917. The next record of Flynn reveals that she secured employment at the Military Hospital in Haifa in December 1919 and was posted to the Ras el-Tin Military Hospital in Alexandria, Egypt in June 1920. She remained there until resigning in January 1921. In 1917, she was awarded the Royal Red Cross Decoration. The final information relating to Flynn reveals that by 1926 she was undertaking both hospital and private nursing in New York City.50 The Ulster Volunteer Force (UVF) was formed in January 1913 as an organisation whose aim was to resist the enforcement of a Home Rule Bill for Ireland. It was a largely Protestant and Unionist force organised along military lines. It carried out drilling, route marches and field manoeuvres throughout Ulster. From its formation, civilian women were heavily involved in UVF activities. With the outbreak of hostilities in August 1914, the UVF concentrated its objective to supporting the war effort as a means of demonstrating loyalty to the Crown.51 Almost immediately, the UVF made efforts to establish a hospital in Belfast. The UVF Headquarters Council offered their

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complete medical facilities to the War Office. After months of raising subscriptions, the UVF opened a base hospital in a building in the grounds of Queen’s University in south Belfast. It had been donated free of charge by Belfast Corporation. Smaller branch UVF hospitals and convalescent homes were established elsewhere throughout Ulster. The hospital in Belfast could accommodate up to eighty patients. The matron of the hospital was Miss Bruce who had trained at the Radcliffe Infirmary in Oxford and had recently been matron of Kasr-el-Aini Hospital in Cairo, an Egyptian government-run establishment with 400 beds. She had been recorded as the matron there in 1900.52 By the time the hospital was formally opened on 8 January 1915, almost £7,000 had been raised through public subscriptions. The Hospital was officially opened by Lady Carson, the wife of Sir Edward Carson, the leader of Ulster’s opposition to Home Rule. This was a highly politicised event which reinforced the loyalty of the people of Ulster to Britain and the Empire.53 The hospital would provide eighty beds with an additional twenty beds available if required.54 In February 1917 the hospital was extended and took over Queen’s University Students’ Union building. It was reported that from 1916 to 1920 ‘thousands of soldiers have been treated and healed in the institution, many of them being from the USA, Australia and Canada, as well as from the British forces’.55 A report in the Belfast News-Letter published in February 1915 stated that there were six sisters and eight assistant sisters supporting Miss Bruce and a detachment of probationers from the Ulster Volunteers Nursing Corps.56 A new matron, Miss M. E. Johnston, was appointed to the hospital in October 1916. She had trained at St Thomas’ Hospital, London and had worked as a Sister in the UVF Hospital since January 1916.57 Unfortunately, there is no comprehensive list of professional nurses who were attached to the UVF Hospital. One nurse identified is Eileen Barrance Crowe who was born in Belfast of English parents. Her father was a professor of music at Queen’s University, Belfast. She had completed her training at the Royal Victoria Hospital in Belfast in March 1915. She left there four months later and subsequently was appointed as a junior sister at the UVF Hospital in August 1915. She only worked there for four months and left to do private nursing with the Belfast Nurses’ Home. After several months she joined the QAIMNS in July 1916 and served both at home and abroad until her appointment as health visitor to Staffordshire County Council in 1920.58 Her short period at the UVF Hospital is certainly intriguing and it begs the question why she left so soon. It would appear that the majority of nurses were part of the Voluntary Aid Detachment (VAD). These were not trained nurses but volunteers who received basic first aid training under the British Red Cross. They were given the misleading title of probationers. It could be interpreted that this helped to lend some legitimacy to the nursing care provided. According to Bowman, ‘it was noted that the doctors and probationary nurses working in these hospitals

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Nurses from Belfast hospitals in the First World War

were all members of the UVF’.59 It is known that many of these volunteer UVF nurses served in France at a hospital near Lyons which had been funded by the Ulster Unionist Women’s Council. However, the existence of UVF hospitals – entangled as they were with the divisive Belfast politics of the period – strongly suggests that female participation in medical activity could result from political affiliations and a desire to demonstrate loyalist credentials and allegiance to the crown in a period when Irish independence appeared imminent. It is also worth mentioning the Mater Infirmorum Hospital opened in 1883 in the mainly Catholic area of north Belfast for the benefit of the sick poor. This was a sister hospital to the Mater Misericordiae in Dublin. In February 1899 the hospital established a school of nursing. A new and larger Mater Infirmorum Hospital opened in 1900 in response to the ever-growing needs of the city. In respect of the Mater Infirmorum Hospital, it made beds available for wounded soldiers for the duration of the war.60 The Sisters of Mercy at the hospital placed thirty beds at the disposal of the War Office.61 Analysis of the various hospitals situated across wartime Belfast provides evidence of a range of problems (shared with other Irish and British cities) including the sudden departure of trained nursing staff at the onset of war and the severe strain placed on staff members involved in caring for wounded soldiers. Nurses who remained in Belfast hospitals during the war years ultimately had to deal with an increased workload, exacerbated by the numbers of soldiers returned to Belfast for treatment. It also reveals much about the composition of Belfast’s hospitals and their uniqueness within a broader network of military hospitals set in place to cope with wartime medical demands. Belfast hospital provision could be inflected by national political tension (as exemplified by the development of UVF hospitals); the treatment of wounded British soldiers being a political act designed to demonstrate loyalty to the state in a period when Irish unity with the United Kingdom was under threat. Conclusion Exploring Belfast nursing provision during the First World War provides insight into the manner by which the Irish medical profession was reorganised to cater for an unprecedented amount of casualties being transported into the city. Prior to the war, Irish nursing (as in other countries) had been professionalised and transformed from its more dubious origins. The prospect of conflict raised the importance of nurses in assisting medical work and caring for patients. Both of these developments brought attractive career prospects for Irish women at the turn of the twentieth century. Nonetheless, the experiences of nursing varied significantly. Many took advantage of the wartime need for nursing staff in distant, perhaps exotic, international locations. Others became

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frustrated at their inability to relocate, a problem made worse by being employed in hospitals with rapidly depleting staff supplies and the mentally strenuous work of caring for a new type of patient: the wounded soldier. Examination of the institutions in which nurses worked has shed further light on their role within a reorganised medical network designed to meet pressing wartime demands. Many aspects of First World War nursing were common to Great Britain and Ireland at the time, as evidenced by an exploration of Belfast hospitals and their nurses. These include the variety of institutions in which nurses worked and cared for the wounded from voluntary hospitals, incorporated nurses’ homes through to purpose-built hospitals for wounded soldiers. One significant aspect was the partisan character of the UVF Hospital and its nursing personnel. This was an overtly Protestant institution with a distinct Unionist agenda which was not initially part of the mainstream War Office plan. While this bias was not unique to Belfast, it did have a significant influence on the care of the wounded in the city. Through the growing support from the people of Ulster, it became an even more prominent focus for the care of the wounded than the Royal Victoria Hospital. The role of the nurses can be summed up in a speech made by Lady Pirrie, as president of the Royal Victoria Hospital, following that institution’s annual meeting. She expressed the following sentiments: ‘In addition to the treatment of civilians, she was sure it had been a great gratification to the medical, surgical, and nursing staff to have had the opportunity of nursing the gallant sailors and soldiers from active service, and to know so many were restored to health and strength by the skill and attention they received there.’62 Notes   1  A. Summers, ‘The mysterious demise of Sarah Gamp: the domiciliary nurse and her detractors, c.1830 –1860’, Victorian Studies, 32: 3 (spring 1989), 365–86, 386.   2  Ibid., 366.   3  A. Bashford, Purity and Pollution: Gender, Embodiment and Victorian Medicine (Basingstoke: Palgrave Macmillan, 1998), p. 25.   4  Ibid., p. 44.   5  A. Witz, Professions and Patriarchy (London: Routledge, 1992).   6  C. E. Hallett, Veiled Warriors: Allied Nurses of the First World War (Oxford: Oxford University Press, 2014).   7  Y. McEwen, In the Company of Nurses: The History of the British Army Nursing Service in the Great War (Edinburgh: Edinburgh University Press, 2014).   8  A. Powell, Women in the War Zone: Hospital Service in the First World War (Stroud: History Press, 2013).   9  W. Maguire, Belfast: A History (Lancaster: Carnegie Publishing, 2009), p. 70. 10  P. Yeates, A City in Wartime: Dublin 1914–1918 (Dublin: Gill & Macmillan, 2011). 11  B. Collins, ‘The Edwardian city’, in J. C. Beckett et al., Belfast: The Making of a City (Belfast: Appletree Press, 2008), p. 173. 12  Summers, ‘Mysterious demise of Sarah Gamp’.

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Nurses from Belfast hospitals in the First World War 13  C. E. Hallett, ‘Nursing, 1830–1920: forging a profession’, in A. Borsay and B. Hunter (eds), Nursing and Midwifery in Britain since 1700 (Basingstoke: Palgrave Macmillan, 2012). 14  Belfast News-Letter (22 November 1861), p. 4. 15  Belfast News-Letter (14 December 1870), p. 4. 16  G. M. Fealy, A History of Apprenticeship Nurse Training in Ireland (London: Routledge, 2006), p. 43. 17  P. Donaldson, ‘The development of nursing in Northern Ireland’ (Ph.D. thesis, University of Ulster, 1983), p. 44. 18  Hallett, ‘Nursing, 1830–1920’, pp. 57–8. 19  Ibid. 20  www.boerwarnurses.com. Accessed 9 January 2015. 21  Y. McEwen, ‘It’s a Long Way to Tipperary’: British and Irish Nurses in the Great War (Dunfermline: Cualann Press, 2006), p. 39. 22  Belfast News-Letter (21 October 1914), p. 6. 23  C. Clear, ‘Fewer ladies, more women’, in J. Horne (ed.), Our War: Ireland and the Great War (Dublin: Royal Irish Academy, 2008). 24  D. Fitzpatrick, ‘Home front and everyday life’, in Horne (ed.), Our War, p. 134. 25  Royal Victoria Hospital League of Nurses Journal, 1 (March 1950), 19. 26  Kew, WO399/595, ‘Mary Best’. 27  D. Fitzpatrick, ‘Home front and everyday life’, in Horne (ed.), Our War, p. 134. 28  R. Marshall, Fifty Years on the Grosvenor Road: An Account of the Rise and Progress of the Royal Victoria Hospital Belfast during the Years 1903–1953 (Belfast: W. G. Baird, 1953), p. 82. 29  British Journal of Nursing (19 July 1913), 53. 30  National Archives, Kew (hereafter Kew), WO32/9343, ‘Report of an Advisory Committee Appointed by the Army Council to Inquire into the Supply of Nurses’, 1917. 31  C. E. Hallett, Veiled Warriors: Allied Nurses of the First World War (Oxford: Oxford University Press, 2014), pp. 47–8. 32  British Journal of Nursing (1 February 1919), 64. 33  Hallett, Veiled Warriors, pp. 47–8. 34  Royal Victoria Hospital League of Nurses Journal, 1 (March 1950), 20. 35  Royal Victoria Hospital League of Nurses Journal, 2 (March 1951), 11. 36  Ibid, 12. 37  Belfast News-Letter (17 April 1919), p. 6. 38  Kew, WO399/4356, ‘Violet Jolly’. 39  R. Clarke, The Royal Victoria Hospital, Belfast: A History 1797–1997 (Belfast: Blackstaff Press, 1997), p. 107. 40  Belfast News-Letter (12 August 1914), p. 5. 41  Belfast News-Letter (6 November 1914), p. 7. 42  Belfast News-Letter (28 March 1919), p. 6. 43  Ibid. 44  J. F. O’Sullivan, Belfast City Hospital: A Photographic History (Ballyhay Books, 2003), pp. 32–3. 45  Belfast News-Letter (14 October 1914), p. 3. 46  Belfast News-Letter (4 December 1914), p. 2. 47  Belfast News-Letter (19 January 1916), p. 2. 48  Belfast News-Letter (13 September 1916), p. 3. 49  Kew, WO399/6299, ‘Hannah O’Driscoll’. 50  Ibid.

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Institutions and medical personnel 51  Ulster Scots Community Network, The Ulster Volunteer Force – January 1913. www.ulster-scots.com. Accessed 9 January 2015. 52  British Journal of Nursing (24 February 1900), 160. 53  Belfast News-Letter (9 January 1915), p. 4, p. 6. 54  Belfast News-Letter (8 January 1915), p. 5. 55  British Journal of Nursing (16 October 1920), 220. 56  Belfast News-Letter (19 February 1915), p. 5. 57  British Journal of Nursing (7 October 1916), 295. 58  Kew, WO399/1906, ‘Eileen Crowe’. 59  T. Bowman, Carson’s Army: The Ulster Volunteer Force, 1910–1922 (Manchester: Manchester University Press, 2007), p. 171. 60  M. Duddy, The Call of the North: A History of the Sisters of Mercy, Down and Connor Diocese, Ireland (Belfast: Ulster Historical Foundation, 2010), p. 126, p. 151. 61  Belfast News-Letter (2 November 1914), p. 7. 62  British Journal of Nursing (15 April 1916), 346.

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10

War work on the home front: the Central Sphagnum Depot for Ireland at the Royal College of Science for Ireland, 1915–19 Clara Cullen

In the summer of 1914 the major political concern in both London and Dublin was the possibility of a civil war in Ireland – the assassination of an archduke in faraway Sarajevo went almost unnoticed. However, by early August the Irish problem had receded far into the background when Germany’s invasion of Belgium brought Britain (and Ireland) into what became a global war. Immediately, military reservists were recalled to their regiments and by the end of the first week in August the first soldiers of the British Expeditionary Force (BEF) were en route to France. While the military mobilised, the civilian population also organised themselves. In Ireland a number of new organisations were established to support the war effort. This chapter provides an example of how voluntary work was organised on the domestic front in Ireland from August 1914 to meet the increasing demands of war, focusing on one specific initiative – the work of the Voluntary Aid Detachments (VADs)1 in the Royal College of Science for Ireland in organising the collection, treatment and delivery of Sphagnum moss as an alternative medical and surgical dressing to cotton wool to the military hospitals of the Great War.2 In recent years there has been an upsurge of interest in the contribution of Irishmen in the Great War. Far less attention has been paid to Irishwomen who served as doctors, nurses, ambulance drivers, dispatch riders and in administrative and catering posts. Few of their names appear in official war lists and only some are commemorated in Great War commemorative plaques and memorials and on Rolls of Honour in various churches and in some institutions in Ireland.3 Those who served overseas are included in one reprinted register4 and the British Red Cross holds indexes and files of the service details of individuals who were volunteers in the First World War.5 Apart from these,

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until recently the contribution of the majority of Irish VAD detachments in the Great War had been largely ignored by historians. Any focus to date has been on those nursing VADs who served in the hospitals of the Western Front, Malta, Alexandria, Cairo and Mesopotamia.6 Yet thousands of volunteers worked in Ireland during the First World War in a wide variety of roles. As Keith Jeffery has commented, ‘the huge numbers of Irish women engaged in undoubtedly less exciting, though still serious, wartime activities as yet constitute a kind of historically hidden Ireland’.7 With a few exceptions, their contribution has been largely forgotten.8 The Great War voluntary initiative in Ireland VADs, field nursing services, had been established on a county basis from 1909. The principal organisations in Ireland associated with first aid work and maintained by voluntary effort before and during the Great War and ‘which different sections of the population, according to taste, ability, or opportunity, have found it within their power to support’9 were the St John’s Ambulance Brigade (StJAB) and the British Red Cross Society (BRCS). Prior to the outbreak of war some women’s first aid units had also been established to support either the Ulster Volunteer Force or the Irish Volunteers.10 Almost immediately after the declaration of war, on 10 August 1914, the wife of the Lord Lieutenant, the indefatigable Lady Aberdeen,11 then president of the British Red Cross in Ireland, convened a meeting at the Royal Dublin Society (RDS) to which representatives of all societies involved in first aid were invited. Aberdeen’s aims were: To consider how Red Cross work could best be promoted in Ireland, and we invited representatives of all societies doing work along the lines of the Red Cross, giving instruction in first aid, nursing, etc … On arrival we found the big hall packed from floor to roof. It was a wonderful representative assembly, the St. John’s Ambulance Association, the St. Patrick’s Ambulance Association, the Department of Technical Instruction, the Irish Volunteers Voluntary Aid Association, the Dublin branch of the Ulster Volunteers, individual members of Cumann-na-Mbhan [sic], though not in a representative capacity, the Women’s National Health Association, the United Irishwomen, and, in addition, the leading members of the medical and nursing professions, who had already offered co-operation.12

The outcome of that meeting was the establishment of a Joint War Committee to coordinate the work of these organisations. The Department of Agriculture and Technical Instruction (DATI) undertook to organise and fund a scheme of first aid classes.13 Within a few months DATI had organised 383 classes, attended by over 10,000 Irish men and women in various parts of Ireland, ‘the Dublin hospitals, at much inconvenience, allowing the students to receive

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Central Sphagnum Depot at the RCScI

practical instruction in their wards’.14 Auxiliary military hospitals were established, often in private houses,15 Ireland’s existing hospitals made wards available for injured soldiers and officers and Lady Aberdeen converted the state apartments in Dublin Castle into a military hospital.16 The BRCS and the StJAB coordinated their efforts, working together from October 1914 to organise the efforts of the groups in Leinster, Munster and Connaught. For the most part the first aid organisations in Ulster did not choose to come under this Joint Committee. The Ulster volunteer groups preferred to report to the Belfast branch of the BRCS or directly to London, a choice reflecting the political divisions and tensions in Ireland from 1912 over Home Rule.17 Under the direction of the BRCS and StJAB Joint Committee, thirty-one Men’s detachments with 1,200 members and eightythree Women’s VADs with 2,927 members were established in various counties over the three provinces.18 The members of these VADs (linked either to the BRCS or the StJAB) were required to have the training in first aid that would enable them to provide support and perform many of the duties which the regular medical services did not have resources to provide in time of war – meeting hospital trains and ships, providing support staff in the auxiliary military hospitals, working as nursing aides, dispensers, caterers, clerical staff and driving ambulances. A joint headquarters was established at 51 Dawson Street (formerly a tailor’s and placed at the disposal of the two organisations by Walter Sexton).19 Workrooms were set up there but later moved to at 64 Merrion Square, Dublin (the lease of which was presented to the Committee by Robert Hayes), for making ‘such garments as pyjamas, pants, vests … and for knitting socks and mufflers’. Later a papier-maché department was established there, making hand supports and splints.20 Number 40 Merrion Square, the use of which was given to the Joint Committee by James Inglis,21 became the Irish War Hospital Supply Depot (IWHSD) which supplied vital medical equipment to military hospitals.22 There, male volunteers made splints, crutches and bedrests. Female volunteers, mainly clerical workers and shop assistants, ‘ladies who were occupied during the daytime’,23 spent their evenings making dressings, bandages and surgical supplies and coordinating the supply of ‘home comforts’ which arrived from working parties throughout Ireland and were dispatched from the IWHSD to soldiers at the Front. As the war continued, other responsibilities were taken on, including the establishment of an Enquiry Bureau for Wounded and Missing Soldiers and Prisoners of War, a clothing depot where consignments of garments of all descriptions suitable for wounded soldiers were received, a National Egg Collection department for receiving gifts of eggs for hospitals accommodating wounded men and later a customsfree depot for receiving tobacco and tea for serving troops. More than 6,000 volunteers worked in these departments or in local work groups during the Great War.24

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The Central Sphagnum Moss Depot at the Royal College of Science for Ireland25 In the Royal College of Science for Ireland (RCScI) in Dublin two VADs were established, one for men and one for women.26 The majority of the members were either members of the College staff, their families or former students.27 The men’s detachment supplied orderlies to the Soldiers’ Central Club, met all the hospitals ships bringing wounded from the Western Front to hospitals in Dublin28 and some worked with the munitions experiments conducted in the RCScI.29 Many of the detachment were prevented by age or physical disability from active service but twelve did join up for the duration of the war and three died.30 Like many other voluntary detachments, a number of the members of the RCScI women’s VAD also served abroad, some for a year or more, some for the duration of the war. One member, Meta Burgess, who had served in France and Malta and then returned to military hospitals in France for the last two years of the war, died on 31 January 1919 after being ‘invalided home from France’.31 The majority of the detachment however, remained in Ireland and expected to be assigned to duties in the auxiliary and military hospitals and nursing homes around Dublin. Instead, they were told in December 1914 that ‘men are urgently needed to meet hospital ships and transport wounded to motors, but women there are enough already [sic]’.32 Their role would be to work in the Irish War Hospital Supply Depot, to help organise and provide comfort packages for soldiers at the Front and to fundraise. However, a new opportunity for these women to make a contribution to the war effort arose in 1915 – a new awareness of the potential of a native Irish moss, Sphagnum moss, as a surgical dressing. By the end of 1914 cotton wool, a standard component of surgical dressings, had become both scarce and expensive. The unexpected and immediate need for an immense supply of surgical dressings after the early battles in Belgium and France made it necessary to identify and experiment with alternative materials. Various options such as wood shavings were explored, but one naturally available one became the preferred choice: Sphagnum moss. This moss had been used as a dressing for wounds in Ireland from medieval times and had been used as surgical dressings in the Napoleonic, Franco-Prussian and Russo-Japanese wars.33 It had been found to have medicinal and absorbent properties and Ireland was a country where one-seventh of the land was bogland at the time – the natural habitat of the moss. The peculiar leaf structure of Sphagnum allows this moss to hold up to twenty times its own weight in water. Dried and treated, it is four times as absorbent as cotton wool so could be left on wounds and would remain comparatively dry for much longer. Mildly antiseptic by nature, the moss dressings were also much lighter and more comfortable for the injured, especially those suffering from bad burns.34

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Central Sphagnum Depot at the RCScI

Research into the medical potential of this moss for surgical dressings began in Britain in late 1914 under the aegis of Charles Walker Cathcart, surgeon at the Royal Infirmary in Edinburgh, an example of how war stimulates scientific investigation.35 Cathcart concluded that ‘even the best prepared cotton, although in a sense very absorbent, lacks the power to retain discharges which is possessed by sphagnum moss’.36 His work came to the attention of John Lumsden37 and Lady Waterford at the IWHSD and also engaged the interests of some of the members of the women’s VAD at the RCScI, many of whom had a scientific background. The main activists were Elsie Henry, wife of the Professor of Forestry at the RCScI and daughter of an eminent London doctor, Thomas Lauder Brunton and Mabel Wright, who was a graduate in botany of the RCScI. Elsie initiated inquiries with Cathcart in Edinburgh through her father, Mabel and a colleague travelled to Edinburgh to see the methods Cathcart was using and DATI were approached to provide accommodation for a Depot at the College. The women’s campaign was successful and in November 1915 the RCScI became the Central Sphagnum Moss Depot in Ireland.38 From November 1915 the remit of the Depot included a sub-depot in Belfast but this was incorporated into the Ulster Sphagnum Moss Association after July 1916 and then came directly under the control of the Director General of Voluntary Organisations in London.39 A committee drawn from the RCScI women’s VAD was formed to manage the enterprise.40 With the permission of DATI and the agreement and support of the RCScI professors and the College staff lecture rooms and laboratories in the College were allocated for the work of the Sphagnum Depot and organisation of the collection and processing of Sphagnum moss for medical purposes began.41 The first step was the organisation of the collection of the correct moss from the bogs of Ireland. The committee wrote to the newspapers and approached private individuals and local organisations appealing for volunteer collectors, including ‘people living in outlying country districts or school children, who could not otherwise have the opportunity [and] would thus be helping directly to alleviate the sufferings caused by war’.42 Teams of moss collectors were organised from almost every county in the south and west and several in the north and east of Ireland. Because of the many varieties of moss the collectors had to be trained to identify the correct types and the RCScI provided them with printed instructions about collecting and correctly handling the moss. The work was hard. The method of collection was to wade into the bog, pull up the moss by the handful and then wring it out. The collected moss was then put into sacks and taken to the nearest centre where the moss could be dried and have dirt, twigs, etc. removed. One collector described the work as follows: No one who has not gathered moss on a bog can realise how arduous is this part of the work. Even under ideal summer conditions the moss can only be reached

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over wet, boggy ground, and when to this is added continuous rain and cold in autumn and winter, which involves wading to obtain it, it can be imagined that the collector’s task is not an easy one.43

Nevertheless, there was no lack of helpers; schoolchildren, girl guides and scouts, members of VADs, local volunteers and parish groups all participated. Even during the severe winter of 1916–17, when the bogs were frozen or covered in snow, the collection of Sphagnum moss continued.44 When collected, the moss was brought to the local centre (and at one stage there were about 200 moss-collecting centres and up to fifty sub-depots reporting to the RCScI),45 sorted, cleaned, thoroughly dried and graded. The RCScI committee were very specific as to how the moss was to be collected, processed and treated. When drying it, ‘Never [sic] put the moss through a mangle to remove excess water … dry in the open air or a well-ventilated room’, and every collector was required to exercise ‘scrupulous cleanliness [sic] in its handling’ before dispatching the dried moss to Dublin ‘in sacks with washable linings’.46 Free or reduced charges were negotiated by the Committee with the Irish railway companies for the transportation of the sacks of dried moss to Dublin. From the various railways termini in Dublin, lorries and carts were provided free by Dublin businesses (such as Wallace and Co. and Tedcastle, McCormick and Co.) to bring the sacks and bales of dried and processed moss to the RCScI.47 Within months of the Depot being established, these women of the RCScI VAD had established an organisation which one commentator described as ‘an organisation which can only be described as a voluntary factory run on scientific lines’.48 At the Central Sphagnum Moss Depot in the RCScI itself the work of processing the bundles of dried moss was dealt with by different departments.49 The moss received at the Dublin Depot was picked over again by the volunteer workers and committee there and graded. This preparation was regarded as the most serious part of the work as ‘it requires constant attention, patience and unlimited time … no greater devotion is shown by any department of the work than in the preparation of the moss for use’ and one volunteer likened the task to the old convict occupation of picking oakum.50 Following this the moss was classified into three grades. The very best moss, the thicker and more absorbent varieties, was put into muslin casings and used entirely for surgical pads. The size and fullness of these pads was carefully standardised in accordance with the requirements of the surgeons who used them. Initially the pads had been made in three standard sizes (12 x 8 inches, 8 x 8 inches, 6 x 6 inches) but by the end of 1916 surgeons were requesting increasingly larger sizes for dressing extensive wounds and for cases of amputation. Less absorbent varieties of the moss were made up into dysentery pads. Nothing was wasted and the inferior moss, the very thin varieties, was used for filling rest cushions of all sizes to be used as stretcher cushions, splint pads and limb pillows.51

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Central Sphagnum Depot at the RCScI

Supporting all of this work in the College of Science was the Tea Department, which was opened for the comfort of workers – tea, bread and butter being provided at 3p a person and the profits, averaging £3 per month, were contributed to the funds of the Depot. Initially some of the Sphagnum dressings were sterilised by requisition of the War Office and, following instructions from Cathcart in Edinburgh, this process was carried out in a room in the College using equipment lent and fitted out by the medical suppliers, Fannin’s of Grafton Street. Later many of the major military hospitals preferred to sterilise the dressings themselves but a number of the smaller medical centres, especially near the front lines, continued to request that the dressings arrive sterilised. Once completed, the Sphagnum dressings were packed into the cases made for the purpose. This was work requiring ‘care to ensure that the packets of dressings arriving at their destination fresh and uncrushed, after their journey of many weeks or even months’.52 From the beginning the men’s VAD at the College took charge of making the supply of cases in which the dressings were dispatched. Wood was cut to size in the Natural History Museum (by kind permission of the director Dr Scharff) and the boxes were made in the engineering department of the College (initially under the guidance of the College carpenter). Fundraising was done to pay for the wood used and when wood became very expensive and scarce, the men’s VAD collected old cases and timber (some of which was donated by various Dublin businesses including Dockrells, Pims and Arnotts) and refurbished them for further use. Apart from the work in sorting and grading the moss and manufacturing the various bandages, pads and cushions, the RCScI depot also had a needlework department which specialised in limb, stump, and abdominal many-tail bandages and splints. These needed to be of a ‘high standard as the life of an average bandage averaged eighteen months of hard wear and tear’.53 All bandages were ‘inspected, labelled and have the requisite number of pins inserted before being put up in packages’.54 Quite often some of these bandages would be included in the consignments of Sphagnum dressings dispatched from Dublin. By early 1916 these boxes of dressings and bandages had been dispatched to military hospitals in Ireland, England, France, Belgium, Alexandria, Salonika and India. In early 1916 the War Office officially recognised the Sphagnum moss dressings as surgical dressings and doubled its requisition of the number of dressings it required each month. The demands on the workers at the Depot increased significantly, the annual report for 1916–17 noting that ‘the demand for Sphagnum dressings has increased enormously during the last half-year and during the summer months a very special effort had to be made to keep pace with the requisitions’.55 In January 1916 the output of surgical dressings at the Depot was 1,300 a month; by August of that year it had increased to 11,444. The total output from all the centres that were under the direction of the

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RCScI Depot was 183,628 in 1916 and the following year this increased to 323,136.56

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Sphagnum moss collection and political upheaval From 1916, domestic political upheaval in Ireland significantly impacted upon wartime medical services and practice. In Easter 1916 armed conflict came to Dublin and members of both of the RCScI VADs had personal experience of injury and death. The conditions in the weeks of and after the Rising were daunting (as discussed in more depth by Barry Kennerk in Chapter 5 in this volume). The tram and train service had ceased, there was no public street lighting, the telephone service was completely controlled by the military and all the usual means of communication were cut off. The College of Science building was closed by the authorities but the members of both VADS were extremely active. Many members of the men’s detachment worked as stretcherbearers and with the ambulances during the week and later some were detailed to help bury the dead. In the first days after Easter Monday members of the women’s detachment reported to the Dublin hospitals, especially the emergency hospital established by Ella Webb, to provide whatever help and assistance was needed. They tended to the wounded from both sides in the conflict.57 Realising the need for Sphagnum surgical dressings some of these women obtained the keys to the College, collected baskets of dressings and delivered them to the Dublin hospitals. In her diary the Depot’s quartermaster, Elsie Henry, described how: We carried the things along Baggot Street and down Fitzwilliam Street into Merrion Square … the fighting is all along Lower Mount Street … Dr. Lumsden and other devoted men in white coats and red crosses were there [in the emergency hospital] … a priest and a clergyman were standing in the hall … the packing room is turned into an extempore theatre with operating tables. There are about twenty cases upstairs. One boy is shot through the lungs and dying. A woman leading a child was coming out crying as I went in. It is awful.58

Elsie and her colleagues continued to deliver surgical dressings to hospitals (including Baggot Street hospital, Sir Patrick Dun’s, Mercers and Dublin Castle) throughout the following days until some semblance of normalcy returned to Dublin.59 The Easter Rising was short-lived but the rapid shift in nationalist politics and the rise in public sympathy towards republicanism in Ireland that followed the execution of the leaders of the Rising impacted significantly on public perceptions of those involved in voluntary wartime work. The Moss Depot reopened on the 8 May 1916. From then on, the demand for Sphagnum dressings increased and, after commencement of the battle of the Somme, it was busier than ever. Importantly, the RCScI Depot established links with

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Central Sphagnum Depot at the RCScI

Canada where interest in the work of the Sphagnum Moss depot at the College had developed. Elsie Henry’s sister-in-law, a Canadian and daughter of Professor John Porter of McGill University, on a visit to Dublin in 1916, had visited the Sphagnum Depot at the RCScI. Following her return to Canada and a report she made on the work of the Depot, her father began to investigate the potential of bogs in Canada as sources for suitable Sphagnum moss, seeing it as ‘a chance for someone who as too old to fight still to be of some use’ to the war effort.60 Samples of mosses from different Canadian bogs were collected and specimens sent to the RCScI for approval. Subsequently, preparation centres, similar to the Irish models, were established in Montreal, Toronto, Halifax and St John, fed by collecting stations throughout eastern Canada, the main source of Sphagnum moss.61 In 1917 medical groups in the United States also developed an interest in the potential medical uses for the moss. The Canadian Sphagnum Association was contacted and the methods they used were studied. In 1917, the University of Washington organised a Sphagnum Association, working on directions received from Montreal and in January 1918 the American Red Cross took control of Sphagnum work in the United States.62 However, in Ireland by 1917 the political climate had changed dramatically and popular support of work in support of the war effort had diminished significantly. Elsie Henry had personal experience of this when she visited a Sphagnum moss sub-depot at Kilgarvan in April 1917, writing that: The workers are all poor, mostly farmers’ daughters, whose mothers do all their share of the home work in their absence … the collecting has been difficult, as the Kilgarvan people have boycotted the workers and also at first tried to prevent the collection of moss. They attacked the moss gatherers one day, men and women … there is a strange and active bitterness.63

Nevertheless the work continued through 1917 and 1918 despite increasing difficulties – the ranks of voluntary workers were depleted, prices of all materials rose, the collection of funds became harder and transport of moss from distant bogs became an increasing problem. Yet the Depot flourished, and at the end of 1918 recorded a record output of surgical moss dressings, dysentery pads and rest cushions for the year of 398,889.64 It continued its work for some months after the end of the war, in response to requisitions from the War Office. On the closing of the military and auxiliary hospitals these requisitions ceased and the Sphagnum organisation in Ireland was demobilised in February 1919, having had a total output of 967,422 surgical dressings and cushions sent to hospitals at home and abroad. The dressings that were sent from Dublin were appreciated by the hospitals that received them and the RCScI Depot’s annual reports included extracts from some of these letters. In 1916 one correspondent wrote, ‘your workers

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may be assured that their efforts could not possibly have been directed to a better purpose’ and another that ‘we shall be delighted to have some Sphagnum Pads every fortnight. We can never have too many, as they are used for so many different things. I should also be glad of Stretcher Cushions. We have so many stretchers just now in use.’65 The following year a correspondent wrote, ‘we had a very severe convoy in this week, and are in desperate need of moss dressings, and should be most grateful if we could have our supply a little earlier’. In another letter, the correspondent wrote that ‘the box of moss dressings you so kindly sent reached Poona two days ago … our Surgeon here thinks very highly of it as a dressing from his experience in Mesopotamia’.66 Conclusion At the Depot in the Royal College of Science for Ireland over 200 volunteers had worked almost without a break from November 1915 to February 1919. The committee had organised up to fifty sub-depots and about 200 mosscollecting centres throughout the country and had supplied surgical dressings to over sixty hospitals in various theatres of war.67 With little business experience, within months of the Sphagnum Moss Depot at the RCScI being established, the women who formed the committee at the Depot had organised an almost countrywide network for collecting, grading and processing the Sphagnum moss, had set up transportation links from remote parts of Ireland to Dublin and from there to military hospitals in Ireland and abroad. Described by Pádraig Yeates as ‘one of the most important initiatives’ in voluntary involvement in the First World War,68 the committee responsible for the Sphagnum Moss Depot had managed its work on the proverbial financial shoestring. In 1915 to 1916 its operating costs were £362 3s. 6p funded by a small grant from the Central War Depot, together with the profit made by the catering department and some donations.69 In the financial year 1916–17 funding included £200 from money raised at a Red Cross race meeting, profits from the Tea department and some financial donations. In 1918, in its last operating year, expenditure was £1,179, funded by £30 from the Alexandra College War Charities Fete, £19 12s. from Miss Wood from ‘sale of silver’ as well as a grant from the Central Depot, a VAD Committee grant and several small donations. These financial accounts are also reflected throughout the entire Voluntary Aid sector during the First World War. All expenses were kept to a minimum; much of the work was done by unpaid volunteers some of whom even hand-delivered letters around Dublin to save postal charges. Continuous efforts were made to fundraise for the work being done in the wide variety of medical and support activities.70 In December 1918 the Quartermaster of the Sphagnum committee, Elsie Henry, and the Secretary, Bea O’Brien, were awarded the Order of the British Empire for the service they had ‘rendered on work connected with the war’.71

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Central Sphagnum Depot at the RCScI

Apart from this acknowledgement, the work and contribution of these women and the volunteers who worked for the Sphagnum Moss Depot from all over Ireland, together with that of other Irish women doctors, nurses and members of VADs everywhere was soon forgotten. The majority of them went back to their pre-war domestic responsibilities although in a world and country very different from 1914. Many of the women who served in the Sphagnum Moss Depot at the College of Science had lost brothers, fiancés or sons in the war and all of them had lost friends.72 The Armistice which effectively ended the Great War on 11 November 1918 was welcomed by the workers at the Depot with overwhelming relief and enthusiasm73 but the political environment in Ireland had changed completely from that of 1914. Ireland was to experience several more years of disruption. There was a bitterly fought war of independence, the division of the island of Ireland into two political entities and the establishment of an independent Irish Free State. The Civil War that followed divided friends and families, including some of the families of the women who had worked so closely together in the Sphagnum Moss Depot. After the establishment of the new Irish state. Some of the lecturing staff at the RCScI either retired or took up the option of moving to England. The RCScI itself ceased to exist as an independent entity, becoming part of University College Dublin in 1926.74 The women who joined the VAD detachment at the RCScI during the First World War were for the most part middle class, did not have to earn their living and were in a position to give their time voluntarily. For some, their choice of the RCScI detachment was linked to the connections of members of their family to the College or to being past students there themselves. They were from a range of religious backgrounds, Church of Ireland, Roman Catholic, Methodist, Presbyterian and one at least had little commitment to any of the organised religions. Similarly, their political affiliations were various, a few were Unionist, the majority were nationalist of one kind or another and some were members of women’s suffrage movements. Like many of the thousands of Irishwomen who volunteered, their involvement in the VAD was not ideological, but was driven by a wish to make some practical contribution to alleviating the suffering caused by war, within the constraints of their domestic or family commitments. The role of women in post-war Ireland did change but not to the extent that some had hoped. In 1918 women over 30 were given the vote (with certain property qualifications) and in 1922 women in the Irish Free State were given full political equality with men. The 1922 Irish Constitution promised that ‘every person without distinction of sex … shall enjoy … the privileges of citizenship’ but the following years were to see Irishwomen deprived of a number of these rights as legislation was passed that restricted women in terms of careers and work outside the home, although freedom of movement and access to education were not so easily taken away.

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As for Sphagnum moss itself, the medicinal properties of Sphagnum moss dressings had been acknowledged and the dressings had proved their worth in the military hospitals of the Great War. As T. Johnston wrote in 1917: Sphagnum [sic] has abundantly proved its worth as a dressing, and has evidently come to stay … a question which will arise and might become acute is the effect on the growth of the bog by constant and indiscriminate collecting … it would be necessary to pay attention to these matters in the exploitation of a bog for surgical dressings. Bog owners have allowed liberties to voluntary collectors for war work which they may not continue for commercial purposes.75

Johnson displayed an awareness of the commercial challenges of utilising Sphagnum moss in the post-war world. Despite the acknowledged medical value of the moss it soon fell out of use. There were some efforts to revisit the use of Sphagnum moss as a war dressing during the Second World War and there have been several initiatives in Ireland, Britain and the United States since to see if it can be exploited on a commercial basis.76 None of these has been successful – the collection of the moss and making of the dressings was very labour-intensive. What made the production of Sphagnum moss dressings viable during the Great War was the work of hundreds of volunteers – men, women and children.

Notes   1  VAD was officially the acronym for the voluntary aid detachment itself but individual members soon became generally referred to as VADs.   2  C. Cullen, ‘War work on the home front: Ireland’s Sphagnum moss and the Great War’, Peatland News, 58 (autumn 2014), 2–3; C. Cullen, ‘Sphagnum moss: the life giving plant’. bbc.co.uk/programme/p0246f46. Accessed 22 January 2015.   3  See www.irishwarmemorials.ie. Accessed 22 January 2015. National University of Ireland, War List: Roll of Honour (Dublin: National University of Ireland, 1919); Trinity College Dublin, War List, February 1922 (Dublin: Hodges Figgis, 1922); Committee of the Irish National War Memorial, Ireland’s Memorial Records 1914– 1918: Being the Names of Irishmen Who Fell in the Great European War, 1914–1918, 8 vols (East Sussex: Naval and Military Press, 2000 [facsimile of edition first published London: Maunsel and Roberts, 1923]).   4  British Red Cross Register of Overseas Volunteers 1914–1918 (London: Savannah Publications, 2004 [facsimile reprint of edition first published London: British Red Cross Society, 1918]).   5  There are about 90,000 of these index records. Some of these are detailed. Others just contain names, addresses, length of service and details of where VADs served and their VAD units. The British Red Cross are presently digitising these cards.   6  See, for example, Y. McEwen, ‘It’s a Long Way to Tipperary’: British and Irish Nurses in the First World War (Dunfermline: Cualann Press, 2006); T. Parkhill (ed.), The First World War Diaries of Emma Duffin: Belfast Voluntary Aid Detachment Nurse (Dublin: Four Courts Press, 2014); ‘A family at war: the diary of Mary Martin, 1 January–25 May 1916’. dh.tcd.ie/martindiary, accessed 15 January 2014.

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Central Sphagnum Depot at the RCScI   7  K. Jeffery, Ireland and the Great War (Cambridge: Cambridge University Press, 2000), p. 30.   8  See M. Downes, ‘The civilian voluntary aid effort’, in D. Fitzpatrick (ed.), Ireland and the First World War (Dublin: Lilliput, 1988), pp. 27–37; E. Reilly, ‘Women and voluntary war work’, in A. Gregory and S. Pašeta (eds), Ireland and the Great War: ‘A War to Unite Us All’? (Manchester: Manchester University Press, 2002), pp. 49–72; T. Burke, ‘The other women of 1916’, History Ireland, 14:5 (September/ October 2006), 8–9; C. Clear, ‘Fewer ladies, more women’, in J. Horne (ed.), Our War: Ireland and the Great War (Dublin: Royal Irish Academy, 2008), pp. 157–82; P. Yeates, A City in Wartime: Dublin, 1914–18 (Dublin: Gill & Macmillan, 2011), pp. 31–4; C. Cullen (ed.), The World Upturning: Elsie Henry’s Irish Wartime Diaries, 1913–1919 (Dublin: Irish Academic Press, 2013). More generally, see M. Hill, Women in Ireland: A Century of Change (Belfast: Blackstaff Press, 2003); C. Clear, Social Change and Everyday Life in Ireland, 1850–1922 (Manchester: Manchester University Press, 2007); K. Adie, Fighting on the Home Front: The Legacy of Women in World War One (London: Hodder & Stoughton, 2013).   9  The Red Cross in Ireland: An Account of the Red Cross Work of the St. John Ambulance Brigade and the British Red Cross Society in the Provinces of Leinster, Munster and Connaught from August 1st 1914 to November 1918 (Dublin: Sackville Press, [1920]), p. 12. 10  S. Pašeta, Irish Nationalist Women, 1900–1918 (Cambridge: Cambridge University Press, 2013), pp. 152–6; S. Pašeta, ‘Women and war in Ireland, 1914–18: “If the nation is to be saved women must help in the saving” ’, History Ireland, 22:4 (July/ August 2014), 24–7. 11  Ishbel Gordon, marchioness of Aberdeen and Temair (1857–1939), wife of the seventh Earl of Aberdeen, Lord Lieutenant in Ireland, 1886, 1905–15. 12  Lord and Lady Aberdeen and Temair, ‘We Twa’: Reminiscences of Lord and Lady Aberdeen Volume Two (London: Collins, 1925), pp. 229–30. 13  G. Fletcher, ‘Red Cross work at the Royal College of Science’, Journal of the Department of Agriculture and Technical Instruction, 19 (1919), 322. 14  Aberdeen, ‘We Twa’, p. 231. 15  In total twenty-four auxiliary hospitals were established, seven of them in or near Dublin. Joint VAD Committee for Ireland, British Red Cross and St John Ambulance, Register of Voluntary Aid Detachments (Dublin: R. T. White, 1916); T. Bowser, The Story of British VAD Work in the Great War 2nd edn (London: Andrew Melrose, [1917]), p. 144; Red Cross in Ireland, p. 4. 16  Aberdeen, ‘We Twa’, pp. 238–9. 17  For more on this see, for example, D. Urquhart, ‘ “The female of the species is more deadly than the male”? The Ulster Women’s Unionist Council, 1911–40’, in J. Holmes and D. Urquhart (eds), Coming into the Light: The Work, Politics and Religion of Women in Ulster, 1840–1940 (Belfast: Institute of Irish Studies, 1994), pp. 93–123. 18  Joint War Committee of the St John Ambulance Brigade and the British Red Cross Society, War Record of Red Cross Work in Leinster, Munster and Connaught 1914–18 (Dublin, 1920). Quoted in Downes, ‘Civilian voluntary aid effort’, p. 29. 19  Irish Times (13 November 1915), p. 8. 20  The papier maché was made on the premises from old cardboard boxes and brown paper and the work was supervised by Letitia Overend and a sculptor, Miss Verschoyle (Red Cross in Ireland, pp. 230–1). 21  Ibid., p. 229. 22  Ibid., p. 12. 23  Ibid., p. 229.

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Institutions and medical personnel 24  Downes, ‘Civilian voluntary aid effort’, p. 29. 25  The Royal College of Science for Ireland had been opened in Merion Street in Dublin in 1911. The buildings are now government buildings. 26  Fletcher, ‘Red Cross work at the Royal College of Science’, 322–6; Red Cross in Ireland; Cullen, World Upturning. 27  The officers of the men’s VAD included Grenville Cole (Commandant), James Pollok, David S. Jardin and W. McFadden Orr with Dr Winter as medical officer (Red Cross in Ireland, pp. 68–70). 28  From 1914 to February 1919 forty-six hospital ships arrived in Dublin, carrying over 19,000 wounded. 29  For more on munitions work at the RCScI during the Great War, see H. H. Jeffcott, ‘Munition work done by the engineering department at the Royal College of Science’, Journal of the Department of Agriculture and Technical Instruction, 19 (1919), 175–9. 30  Edward Pullin was killed in action in France in 1916 (‘UK, Soldiers died in the Great War, 1914–1919’. www.ancestry.co.uk. Accessed 16 April 2015). Henry Glasgow, aged 20, died in 1917 of ‘illness contracted on active service’ (Ireland’s Memorial Records, 1914–1918, vol. 3, p. 302). Keith Loggie, aged 19, died of wounds in France in 1917 (ibid., vol. 5, p. 226). 31  Ireland’s Memorial Records, 1914–1918, vol. 1, p. 286. 32  Cullen, World Upturning, pp. 81–2. 33  T. Johnson, ‘Sphagnum’, in Irish War Hospital Supply Organisation, Third Annual Report of the Sphagnum Department of the Irish War Hospital Supply Organisation (Royal College of Science Sub-Depot) Acting as the Central Sphagnum Depot for Ireland (Dublin: Thom, 1917), pp. 3–6; J. W. Hotson, ‘Sphagnum as a surgical dressing’, Science, 48:1235 (30 August 1918), 203–8, 204. 34  J. B. Porter, ‘Sphagnum moss for use as a surgical dressing: its collection, preparation and other details’, Canadian Medical Association Journal, 13 (March 1917), 201–20; J. B. Porter, ‘Sphagnum surgical dressings’, International Journal of Surgery, 30 (May 1917), 129–35; Johnson, ‘Sphagnum’, pp. 3–6; Hotson, ‘Sphagnum as a surgical dressing’, 203–8; G. E. Nichols, ‘War work for bryologists’, Bryologist, 21:4 (July 1918), 53–6; P. Ayres, ‘Wound dressing in World War I: the kindly Sphagnum moss’, Field Bryology, 110 (13 November 2013), 27–34. 35  C. W. Cathcart, ‘Cheap absorbent dressings for the wounded’, British Medical Journal, ii (24 July 1915), 137–9, 137; C. W. Cathcart, ‘Methods of preparing Sphagnum moss as a surgical dressing’, Lancet, 187 (15 April 1916), 820–2. 36  C. W. Cathcart, paper delivered 16 June 1916; quoted by Porter, ‘Sphagnum moss for use as a surgical dressing’, 204. 37  John Lumsden (later Sir John) (1869–1944), was the Commandant of the St John’s Ambulance Brigade in Ireland. He was physician to Mercer’s Hospital in Dublin and chief medical officer to the Guinness brewery. In 1939 he was a founder member of the Irish Red Cross Society. 38  Irish War Hospital Supply Organisation, First Annual Report of the Sphagnum Department of the Irish War Hospital Supply Organisation (Royal College of Science SubDepot) Acting as the Central Sphagnum Depot for Ireland (Dublin: Thom, [1917]); Cullen, The World Upturning, p. 127. Irish War Hospital Supply. Royal College of Science Sub-Depot Acting as the Central Sphagnum Depot for Ireland under the control of the Director General of Voluntary Organisations, Report for 1915–1916 (Dublin: Thom, 1916). 39  First Annual Report of the Sphagnum Department, p. 3. 40  The Committee of the RCScI Sphagnum Moss Depot were Henrietta Fletcher (the wife of Assistant Secretary in regard to Technical Instruction at DATI), Harriet

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Central Sphagnum Depot at the RCScI Reed (a qualified nurse who ran a nursing home in Landsdowne Road), William Winter (physician to Dr Steevens hospital), Elsie Henry (wife of Augustine Henry, Professor of Forestry), Mabel Wright (wife of William Wright of the Geological Survey and a graduate of RCScI), Mrs Wilson (wife of James Wilson, Professor of Agriculture), Blanche Vernon Cole (wife of Greville Cole, Professor of Geology and a former student at RCScI), Bea O’Brien (a member of United Irishwomen) and Mrs Jardin (wife of David Jardin, a lecturer at RCScI). 41  Initially the work was carried on the advanced bacteriological laboratory at the College and as the work of the Depot increased more rooms were made available. Irish War Hospital Supply Organisation, Second Annual Report of the Sphagnum Department of the Irish War Hospital Supply Organisation (Royal College of Science SubDepot) Acting as the Central Sphagnum Depot for Ireland (Dublin: Thom, 1917), p. 3. 42  M. C. Wright, ‘Sphagnum Moss’, Irish Times (24 March 1916), p. 7; Irish Independent (25 March 1916), p. 2. Lists of moss collectors were published in the annual reports of the Sphagnum Department. See, for example, Second Annual Report of the Sphagnum Department, pp. 18–20. 43  Third Annual Report of the Sphagnum Department, p. 9. For another description of collecting the Sphagnum moss, see M. Pakenham, Brought Up and Brought Out (London: Cobden-Sanderson, 1938), pp. 44–5. 44  Second Annual Report of the Sphagnum Department, p. 5. 45  See, for example, ibid., pp. 8–9 and pp. 18–20. 46  Sphagnum Moss (Dublin: Sphagnum Department, IWHS Sub-Depot, [n.d.]), p. 2. 47  Irish War Hospital Supply [Organisation]: Royal College of Science Sub-Depot under the control of the Director-General of Voluntary Organisations, Report for 1917–1918 (Dublin: Thom, 1919), pp. 7–8. 48  Red Cross in Ireland, p. 236. 49  Ibid. 50  Second Annual Report of the Sphagnum Department, p. 5. 51  First Annual Report of the Sphagnum Department, p. 5. 52  Second Annual Report of the Sphagnum Department, p. 14. 53  First Annual Report of the Sphagnum Department, p. 9. 54  Ibid. 55  Second Annual Report of the Sphagnum Department, p. 5. 56  Third Annual Report of the Sphagnum Department, p. 9. 57  The Irish War Hospital Supply Depot in Merrion Square had been converted to an emergency hospital during the Easter Rising, with Ella Webb as medical officer and some members of the women’s VAD worked there, together with John Lumsden and the medical officer to the Sphagnum Depot, William Winter. 58  Cullen, World Upturning, p. 153. 59  For more on medical aspects of the Easter Rising, see A. Kinsella, ‘Medical aspects of the 1916 Rising’, Dublin Historical Record, 50:2 (autumn 1997), 137–70. 60  Porter, ‘Sphagnum moss for use as a surgical dressing’, 202. 61  For more on this, see N. N. Riegler, ‘Sphagnum moss in World War I: the making of surgical dressings in Toronto, Canada, 1917–1918’, Canadian Bulletin of Medical History, 6 (February 1989), 27–43. 62  Hotson, ‘Sphagnum as a surgical dressing’, 203–8. 63  Cullen, World Upturning, p. 185. 64  Third Annual Report of the Sphagnum Department, p. 9. 65  Second Annual Report of the Sphagnum Department, p. 7. 66  Third Annual Report of the Sphagnum Department, p. 12. 67  Nineteenth Annual Report of the Department of Agriculture and Technical Instruction, 1918–19, HC 1920 [Cmd. 929] ix.271, p. 357.

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Institutions and medical personnel 68  Yeates, City in Wartime, p. 33. 69  See, for example, First Annual Report of the Sphagnum Department, p. 12. 70  Despite the public disillusionment with the war contributions to the Red Cross the StJAB and to VAD activities increased in the last years of the war. See Downes, ‘Civilian voluntary aid effort’, pp. 30–2. 71  Cullen, World Upturning, pp. 218–19. 72  For more on this, see V. Nicholson, Singled Out: How Two Million Women Survived without Men after the First World War (London: Penguin, 2008). 73  Cullen, World Upturning, pp. 213–14. 74  See C. Cullen and O. Feely (eds), The Building of the State: Science and Engineering with Government on Merrion Street (Dublin: University College Dublin, 2011). 75  Third Annual Report of the Sphagnum Department, pp. 5–6. 76  See Irish Times (13 August 1942), p. 3; Irish Independent (25 July 1941), p. 2; I. Fraser, ‘War hospital supply depots’, British Medical Journal, ii (21 October 1939), 829; Riegler, ‘Sphagnum moss in World War I’, p. 28; Irish Independent (13 August 1985), p. 5.

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11

On the brink of universalism: the Emergency Hospital Services in Second World War Northern Ireland Seán Lucey

The Second World War was a period of change in Northern Ireland. In a political climate traditionally dominated by the constitutional question, social issues came to the fore when Belfast’s and Northern Ireland’s wartime experience exposed the failures of the interwar policies. Across the United Kingdom, welfare reform was central to policy debates, especially after the publication of the 1942 Beveridge Report which recommended widespread reform of social welfare and formed the basis of the post-war welfare state. The state’s obligation to provide medical attention to a civilian population suffering from exogenous threats of aerial attacks led to the inauguration of the Emergency Hospital Services (EHS) – later the Emergency Medical Services – and allied services including medical services, a casualty bureau, blood transfusion and pathological service. This wartime reorganisation of health services has been viewed as vital to paving the way for the universal, centralist and free-at-the-point-ofcontact National Health Service (NHS) that came into effect in 1948, and for specifically providing the model for the NHS Regional Hospital Boards.1 There remains, however, limited historical examination of the scheme. The EHS has been described in its 1950s official history (with a Northern Irish section), but understandings on its regional or local impact remain limited.2 Such a lacuna is anomalous considering the extensive historical exploration of pre-NHS and interwar local health which has demonstrated an expanding and, at times, vibrant, mixed economy of voluntary and public sectors that was complex but increasingly integrated. Overly negative interpretations have been effectively challenged which problematises the long-held view that the NHS represented a radical departure from what went before.3 In turn, the EHS is important because it further explains the transition from the localist and mixed economy of the interwar years to the universal and centralist NHS. The

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chapter’s concentration on Northern Ireland provides insights into the local, regional and devolved contexts of the EHS and 1940s healthcare. This chapter not only informs understandings on the UK-wide NHS, but also demonstrates the differing trajectories of health services within an island of Ireland framework. Although health services in Northern Ireland and independent Ireland took increasingly contrasting paths post-partition – especially in relation to funding and poor law reform – many similarities persisted for much of the interwar years as a result of a common legislative legacy, strong voluntary sectors, and limited local authority public health. The 1940s brought major transformation and reform of UK health services which Northern Ireland fully participated in. Fervent opposition from the Catholic Church and medical professional interest ensured a universal NHS-type system was never introduced in independent Ireland; instead, it relied on a traditional mixed economy where entitlement was based on complex means-tested criteria which varied from service to service along with a strengthening private sector.4 The 1940s embedded health service difference in the two states in Ireland. Recent historiographical work has addressed much of the Northern Irish economic, political, social and sexual experience of the Second World War.5 Some wartime public health measures, along with the establishment of the Northern Irish welfare state, have been explored by historians and political scientists; however, the war’s impact on health services is under-researched and the EHS in the province has not received historical examination.6 This chapter highlights how the EHS led to the coordination of hospitals, expansion of entitlement to health provision and altered funding for hospital services. It also examines the nexus between local authorities, Northern Ireland’s Stormont administration and the Westminster government. The EHS, it is argued, bestowed greater financial responsibility on both Stormont and London for services traditionally viewed as the remit of local government and voluntary providers in the United Kingdom. These developments helped to pave the way for nationalised health services in Northern Ireland. This chapter generally explores Northern Ireland although the focus is primarily on Belfast. The city was the site of the majority of the province’s acute and specialist hospitals, and was central to the EHS’s plans. It was also the target of most aerial attacks during the war in Northern Ireland. The Northern Irish experience of war differed from both Great Britain and independent Ireland. In contrast to the rest of United Kingdom, conscription was not introduced in the region in an attempt to assuage nationalist and Catholic unrest. During the initial stages of the war Northern Ireland did not suffer from the same food rationing as in Great Britain. The region did not suffer from the same volume of aerial attacks as some parts of Great Britain, although the spring 1941 Belfast Blitz was intense and the city suffered from the highest loss of life in any single attack outside of London.

EHS in Northern Ireland during the Second World War

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Hospitals on the eve of war On the eve of the Second World War Northern Ireland’s healthcare was the focus of extensive criticism from contemporary medical officials.7 Hospital and personal healthcare was provided by multiple local government, charitable and state insurance sectors. Historians have described such a system as a mixed economy of healthcare.8 Several layers of local government provided different branches of health services. The poor law system, run by boards of guardians locally, administered poor law infirmaries and the dispensary system. The continuation of workhouses until the 1940s remained a blight on interwar healthcare and the region lagged behind both the Irish Free State and Great Britain where the poor law had been formerly disbanded by the early 1930s.9 Some local poor law reform was evident and eleven former workhouse infirmaries were reconfigured into district hospitals which signalled a break from the poor law. Fifteen poor law hospitals, including the Belfast infirmary, existed by the late 1930s.10 These institutions did develop medically but such relief remained linked to poverty while boards of guardians added to the labyrinth of health administration. Local government public health authorities – Belfast and Londonderry Corporations and urban and rural district councils and county councils – provided another layer of local health provision. These authorities provided personal health services such as maternity and child welfare, school medical services and treatment for tuberculosis and venereal disease. Institutions run by public health authorities included infectious disease hospitals, mental health institutions and sanatoriums. The Ministry of Home Affairs, whose remit included judicial and policing responsibilities, was the central government body that oversaw all local authorities. The lack of a government department solely for health and welfare, such as Britain’s Ministry of Health or the Irish Free State’s Department of Local Government and Public Health, undermined interwar Northern Irish public health. Furthermore, central–local government relations throughout this period were marked by mutual tension, disputes over funding and unwillingness by either side to take responsibility for the expansion of health services.11 Public health was further undermined by the devolved government’s failure to keep pace with developments in Great Britain. For example, the 1931 Housing Act and the 1936 Midwives Act introduced in England and Wales were either not legislated for or only partly implemented in Northern Ireland. These services were a devolved or transferred responsibility and not substantially supported by Westminster. Strong central government support for public health measures in England and Wales could act as a catalyst for local authority expansion.12 The Northern Irish government failed to provide such support and measures lagged behind wider British trends which ensured differing public health service trajectories across the United Kingdom’s constituent countries.13

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Public health services were slow to grow on both sides of the Irish border. As demonstrated by Greta Jones, funding for tuberculosis provision increased slowly although benefits were generally higher in the north than the south.14 Other areas of local authority health such as maternity and child provision were similarly underfunded in the Free State and in Northern Ireland, especially when compared to local authority expenditure in Great Britain.15 Voluntary hospitals were another health sector which provided general and specialist hospital care. Similar to Great Britain, Northern Irish voluntary hospitals were more prestigious than their local authority and poor law counterparts. The general voluntary hospitals focused mostly on acute and curable cases while the longer-term ‘chronic’ and infectious sick remained largely in poor law care. Voluntary hospitals were also deeply connected with the medical profession and both Belfast’s general institutions – Royal Victoria and Mater Infirmorum – acted as teaching hospitals for Queen’s University’s medical school. Belfast’s network of voluntary hospitals of two general and eight specialist institutions was bigger than that of many British cities although smaller than Dublin’s large system.16 Belfast’s voluntary hospitals’ finances were traditionally based on charitable subscriptions, bequests and donations, although they became reliant on mutualistic industrial workers’ contribution schemes, characteristic of British developments, during the interwar years.17 Voluntary hospitals were governed by independent management which resisted state encroachment and influence. Entitlement to voluntary heath was often predicated on membership of contribution schemes and deservingness to charity. Voluntary hospitals in the Free State had different sources of funding. Proceeds from the government-run Irish Hospitals’ Sweepstakes, the lack of a substantial industrial working class to establish contribution schemes, and the early development of private beds, wards and blocks in Free State hospitals ensured difference in hospital finances, entitlement, and management between the two Irish states.18 Another strand of health provision was national insurance. In 1930, medical benefit and the panel doctor system for the insured was finally introduced in Northern Ireland by the Minister of Labour, John Miller Andrews, after its exclusion from Ireland under the original 1911 National Insurance Act.19 Andrews was representative of the step-by-step strand in Ulster Unionism which attempted to maintain Northern Irish parity with British welfare developments. The Northern Irish government was ultimately controlled by politicians – most conspicuously the Minister for Finance, Hugh MacDowell Pollock – who were committed to conservative fiscal policies and balanced budgets.20 Medical benefit was a boon to the insured workers and their families, close to 417,000 in 1938 or around one-third of the Northern Irish population, who now had a similar set of entitlements as their counterparts in Great Britain.21 These services were not extended to the majority of the population while the insured were not covered for hospital benefit.

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EHS in Northern Ireland during the Second World War

As already highlighted, historians of English and Welsh health have uncovered a more dynamic, responsive, expanding and democratic service than traditional understandings allow. Northern Ireland also witnessed growth in local authority public health budgets, voluntary hospital beds and witnessed poor law medical reform. As the interwar period progressed, greater integration between the sectors emerged. For example, by the late 1930s patient referral mechanisms had emerged which allowed for the flow of patients from Belfast Corporation’s maternity and child welfare centres to the voluntary Royal Maternity and poor law Jubilee maternity hospitals.22 Patients, especially the infectious disease sick, were frequently sent across poor law and municipal authorities which often involved budgetary transfers between sectors.23 This suggests that the traditional interpretation of Northern Irish interwar health services as being underfunded, piecemeal and lacking in integration have been overly harsh.24 However, Northern Ireland’s and Belfast’s obstinately high mortality rates – infant and maternal mortality rates compared to Great Britain – indicate serious public health shortcomings which undermine any overly positive interpretation of the region’s health performance. Despite the above examples, a major criticism remained the lack of integration. This was exacerbated by the failure to establish a government body such as Whitehall’s Ministry of Health resulting in the spread of responsibility for health services across several ministries. The Carnwath inquiry into Belfast’s pre-Second World War public health (which reported in 1942) identified that child welfare overlapped between poor law, municipal and education authorities leading to much confusion over obligations; throughout the 1940s various reports, professional bodies and medical expert groups concentrated their criticisms on this issue.25 Interwar Belfast and Northern Ireland did witness growth in healthcare but the region also lagged behind many other regions in the United Kingdom in some key areas making the need for reform even more apparent. The introduction of the Emergency Hospital Service The likelihood of war forced the British government to reorganise civil defence. By mid-1938 Whitehall’s Ministry of Health established the EHS in England and Wales to provide a wartime hospital service. Under the scheme all hospitals – voluntary and local authority – were organised into regions for dealing with the war-related sick (initially service personnel and war/air attack causalities, but it later included war workers).26 The ministry upgraded facilities and paid hospitals for beds. It also coordinated medical staff while consultants were paid full-time salaries and distributed among the regions.27 The ministry set performances standards, introduced national pay scales, and provided 80,000 new beds in Great Britain.28 This represented a significant change in British hospitals and amounted to a national health service funded and organised by

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central government, although the ordinary civilian sick were not covered by the scheme.29 In Northern Ireland, the pending war was viewed as an opportunity to integrate the complex hospital structure. In April 1939, the Northern Irish branch of the British Medical Association (BMA) believed that the war offered a ‘great opportunity for comprehensive reorganisation’ and ‘closer co-operation’ between hospitals.30 The Northern Irish BMA had already taken the lead in organising medical service for the armed forces. Acting under the direction of the BMA’s London-based Central War Emergency Committee, it was charged with the registration and recommendation of Northern Irish medical practitioners in the armed forces, examination of army recruits and other ‘army needs’.31 Air Raid Precaution (ARP) plans were in motion since 1935 which included some medical aspects such as first aid posts and ambulances.32 The reorganisation of hospitals was not initiated until May 1939 when the BMA and voluntary hospitals representatives met with Ministry of Home Affairs’ officials including the chief medical officer Dr J. M. McCloy, and Belfast Corporation’s Medical Officer of Health, Charles Thomson. The government committed to purchasing supplies for first aid posts, training of nurses, and staffing of hospitals while questions regarding mobile X-rays and emergency lighting plants were discussed. The coordination of hospitals under an emergency scheme was deferred until the opinion of hospitals’ staff was ascertained.33 Attempts to bring about a wartime hospital scheme were beset with potential complications. First, there was uncertainty regarding how large of an emergency service was needed in Northern Ireland. By June 1939, Ministry of Home Affairs’ officials complained that EHS plans were delayed by limited information on potential casualties.34 While it was estimated that on the outbreak of war British casualties could amount to 35,000 on the first day, potentially rising to 322,000 in the first fortnight, no concrete Northern Irish figures could be given by London or Belfast officials.35 In August 1939, Whitehall’s Ministry of Health, acting on Committee of Imperial Defence advice, informed Northern Irish officials that any attack would be far smaller than in Great Britain because aircraft had to travel farther and through British defences. In turn, it was believed that any calculation of casualty rates on British estimates would produce ‘very misleading results’.36 Ambiguity over the extent that war would affect Northern Ireland impeded plans. Other obstacles to coordination included the potential for dispute between the various healthcare stakeholders. Traditionally, the voluntary hospitals viewed government expansion in health as a derogation of their powers.37 Potential opposition was offset by the government’s acquiescence to the medical profession’s concerns. In July 1939 the Northern Irish BMA recommended that a hospital officer should be appointed to develop a scheme acceptable to the hospital authorities, medical staffs and ministry.38 The Ministry of

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EHS in Northern Ireland during the Second World War

Home Affairs was anxious to placate the medical profession whose cooperation, as in Great Britain, was vital for the scheme’s implementation and to overcome central government’s lack of medical expertise.39 In turn, a medical leader named Dr F. M. B. Allen – a paediatric consultant in the voluntary Belfast Hospital for Sick Children – was appointed as the EHS’s hospital officer. He was also the secretary of the Northern Irish BMA branch which, according to government officials, gave him ‘unusually wide contacts with[in] the medical profession’.40 Allen had already lobbied the ministry on the rate of payment for participating doctors in the scheme.41 His appointment eased relations between the government and medical profession. In September 1939, the Minister of Home Affairs, Sir Dawson Bates, in the Stormont parliament expressed his ‘warmest thanks’ to the medical profession for their cooperation in the planning for the emergency services.42 The Emergency Hospital Service in action In September 1939, the EHS scheme was announced by the ministry and was included in that year’s Civil Defence Act (Northern Ireland). The scheme, which was based on Allen’s recommendations, divided Northern Ireland’s hospitals into four groups to deal with casualties in the event of an air attack. The first group was to receive the majority of patients and included Belfast’s main general hospitals – Royal Victoria Hospital, Mater Infirmorum and the Belfast Union Hospital. These were supported by eight voluntary hospitals in the Belfast region – considered to be most in danger of attack – which were to receive a limited number of casualties and specialist cases. The second group included district hospitals, county infirmaries and cottage hospitals in Counties Antrim and Down, a region also believed to be under threat. The third group was made up of all Northern Irish fever, mental hospitals and sanatoriums which were to receive ordinary medical cases from hospitals in the first and second groups. The final group of hospitals included four voluntary hospitals that would only be called upon in exceptional circumstances.43 Such hospital groupings indicated the influence of ‘hierarchical regionalism’ in Northern Irish health planning; a term coined by the comparative health historian Daniel M. Fox to describe what he viewed as the key organising principle in British and American health services during this era.44 Promoted by many medical experts, especially among hospital specialities, such ideas promulgated the organisation of health services around regional structures to ensure that an area’s services worked together to establish referral mechanisms and rationalise patient flows to appropriate institutions. The 1920 Dawson Report is generally credited with the popularisation of regional health policies, especially among leading civil servants, although such trends can be traced to the development of late nineteenth-century isolation hospitals.45 Case studies of some interwar British cities and regions, specifically Aberdeen and

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Gloucestershire, have identified regionalised health services.46 In these cases, influential networks of members of voluntary hospitals, medical schools and local government public health departments reached a consensus which promoted regional and integrated medical services. These local manifestations of Fox’s ‘hierarchical regionalism’ point towards the importance of ‘medical technocrats’ in instigating reform which eventually led to the NHS. The dominance of such a non-partisan and value-free medical expertise as the key driver of change, however, has been widely contested, and the prominence of the labour movement in promoting health reform, in conflict with conservative and vested interests, has been asserted.47 In Northern Ireland the EHS was born out of consensus in a region where the often intractable political and religious relations were of a different hue than in Great Britain. This was probably best demonstrated when the Mater Infirmorum Hospital, run by the Catholic Sisters of Mercy, participated in the scheme. Northern nationalists and the Catholic religious hierarchy opposed much of the war effort and prevented conscription that was introduced in Great Britain in 1939. The Mater Infirmorum had a complex relationship with the Northern Irish state. At one level it was part of the Catholic shadow state made up of churches, schools and other welfare institutions which acted as an alternative sphere to the Protestant-dominated government and public institutions.48 At another level it was part of Belfast’s medical elite and was a teaching hospital for Queen’s University’s medical school. Tensions between the hospital and the state would ultimately see the Mater remain outside the National Health Service until 1972.49 In the context of the Second World War, the Mater Infirmorum’s involvement in the EHS represented the engagement of Belfast’s key Catholic medical institution with the state. This significance was evident when the Ministry of Home Affairs was informed that the hospital’s ‘whole-hearted’ cooperation was supported by teachers, priests and the religious hierarchy including the Archbishop of Armagh, Dr Joseph MacRory, and the Bishop of Down and Connor, Dr Mageean. Government officials noted that government ministers should refute any public statements regarding the lack of Catholic support although it was acknowledged that nationalist ‘political attitude’ was unchanged.50 It has been contended that the experience of war in Great Britain led to increased social solidarity which ultimately helped to create the welfare state and nationalised health services.51 While political and religious divisions continued in Northern Irish society, the onset of war did lead to mutual support in the organisation of health. Such consensus indicates that health technocracy often transcended wide societal fissures. A key objective of the scheme was to connect the casualty hospitals in the danger zones with institutions outside these areas. This allowed for the transfer of air raid casualties to appropriate hospitals, and patients’ evacuation to outer institutions, irrespective of whether under voluntary or local government management.52 Such patient flow was orchestrated by the EHS hospital officer

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EHS in Northern Ireland during the Second World War

whom the hospitals furnished daily reports to. This effectively cut through the multiple layers of poor law, voluntary, municipal and county council authorities which hindered interwar provision. Consultancy services were also developed and mobile medical specialist teams were set up which hospitals in the EHS scheme could call on.53 Previously, specialist physicians and surgeons were disproportionately located in Belfast’s voluntary hospitals with limited expertise in local authority and provincial hospitals. Furthermore, outpatient specialist treatment was traditionally limited to the voluntary sector where entitlement was often predicated on poverty, membership of a hospital contribution scheme or fee payment. New procedures were developed under the EHS for specialist outpatient services which allowed participating hospitals to send their patients to the outpatient departments of other hospitals for a second opinion or special investigation.54 Such integration of specialist services between hospitals was previously lacking. New financial structures Another important development was central government’s acceptance of financial responsibility for the EHS. Voluntary hospitals previously received limited if any state funds and were reliant on subscriptions, endowments and contribution schemes, while local authority hospitals were funded mostly through local taxation. Under the EHS scheme the Northern Irish Ministry of Home Affairs funded any additional cost related to the treatment of war casualties and any structural work needed to adapt hospitals. Treatment of air raid casualties was paid on a capitation basis at a rate negotiated between Whitehall’s Ministry of Health and the British Hospitals’ Association.55 Additional medical equipment such as beds, X-ray apparatus and operating theatre equipment was provided by the Ministry of Home Affairs although this remained the property of central government. Even the best-equipped hospitals, by 1939 standards, needed some upgrading while in more limed hospitals operating theatres were introduced.56 The EHS also added over 1,000 hospital beds to the pre-war total of 4,700 general beds.57 During the interwar years British local authority health was marked by much localism although central government funding remained important for healthcare expansion.58 In Northern Ireland central and local government were embedded in intractable disputes over finances which greatly inhibited development. The pending war and subsequent need to realign hospitals overcame such entrenched positions. Stormont officials could not expect or rely on local authorities to meet the cost of a service which was considered to be of national importance. Local authorities still had to pay 30 per cent of the cost, in contrast to the voluntary hospitals that were fully recompensed.59 Central government now funded services in local authority and voluntary hospitals, which it had previously steadfastly resisted. The threat of war forced the Northern Irish

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government to accept a greater role in the lives and health of its citizens than it was previously willing to undertake. The EHS also impacted on the financial relationship between the devolved Northern Irish state and the London or ‘Imperial’ government, which was originally based on the Joint Exchequer Board, but from 1925 a system of annual negotiations emerged. During the interwar years Westminster subsidised key social security measures including the OAP and unemployment benefits while in 1925 and 1930 pensions and health insurance were introduced at wider UK levels.60 In contrast, hospitals were viewed as a devolved and transferred service and received limited – besides sanatoriums and mental institutions which received Imperial grants per patient – direct financial support from London. The impetus for the EHS in Northern Ireland came from Britain. In turn, the Northern Irish government pushed London to accept financial liability for the scheme. In August 1939, Whitehall’s Ministry of Health agreed that the Northern Irish ministries were acting as ‘agents’ for the Westminster government in civil defence matters and that the cost of treating air raid casualties should fall on the ‘Imperial Exchequer’.61 The Northern Irish government, notoriously slow to invest in social services, could now rely on London to fund the EHS. Westminster’s greater commitment to Northern Irish hospitals was a new departure and pre-empted London’s financial commitment to the region’s healthcare after the war. The financial relationship between Belfast and London became strained after the Belfast Blitz in 1941 and Northern Irish officials sought £50,000 directly from the Ministry of Health to fund the cost of the EHS, evacuation and billeting. London’s Ministry of Health complained that it had no authority over civil defence in the region and challenged the belief that the Northern Irish government ministries were ‘merely’ its agents in the delivery of services.62 After much discussion between Whitehall’s Ministers of Health and Treasury and Northern Ireland’s Ministries of Finance, Public Security and Home Affairs, a new system of funding for civil defence emerged. In relation to the EHS, expenditure had to be agreed by the Northern Ireland Ministry of Finance and voted on by the Stormont parliament, although the cost would ultimately be met by the Imperial Exchequer. It was agreed that the Ministry of Health held no accounting liability but would offer advice and expertise if needed.63 This case demonstrated the complexities related to the funding of hospitals and health services conceived in London but administered and developed in Belfast. The Ministry of Health refused to accept direct financial responsibility for services which it did not control directly while Northern Irish authorities were unwilling to give up control. It also highlighted that while hospitals were increasingly organised on the same principles across the United Kingdom, Northern Ireland continued to be marked by regional difference in funding

EHS in Northern Ireland during the Second World War

and structure. London, however, ultimately accepted financial responsibility for the EHS which strengthening London and Stormont relations and the former’s role in Northern Irish health services.

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Running of the Emergency Hospital Services Initially, the EHS made limited impression on health services. On its introduction, hospitals were informed to restrict admissions to urgent and acute cases while institutions in danger areas were to send fit enough patients home. With the unlikelihood of aerial attack, hospitals were soon informed that they could revert to a more liberal admission policy.64 The newly established Ministry of Public Security took over the EHS in 1940 from Home Affairs. At this stage, the EHS remained limited to a small number of armed forces casualties and children under the evacuation schemes.65 The EHS was brought into action during and after the Belfast Blitz of spring 1941 in which the city suffered from numerous air attacks. An estimated 56,000 homes were damaged leaving 100,000 people temporarily and 15,000 permanently homeless.66 There was also a mass evacuation from Belfast. The EHS and Belfast’s hospitals were overwhelmed by the volume of air casualties which amounted to 846 fatalities and 2,494 injured. Hospital services were impeded by the destruction of the Ulster Hospital for Children and Women and the Belfast Hospital for Diseases of the Skin.67 Response to air raid casualties was further undermined by inefficient ambulance and first-aid parties.68 Within the context of such pressure on the government, key medical figures sought the EHS’s expansion. Many of Belfast’s hospitals experienced a precipitous rise in ordinary patient waiting lists because of reserved beds under the EHS scheme. After the April 1941 air attack the Royal Victoria’s medical staff called on the EHS to partially transfer its ordinary work to a hospital outside the city.69 In May 1941 representatives of Belfast’s main voluntary hospitals – Royal Victoria, Mater and Royal Maternity – put together a plan to convert the municipal mental institution, Purdsyburn, into a central EHS hospital. It was envisaged that this would relieve the city’s hospitals of some air raid casualty duties and free up beds for more casualty and ordinary patients. The voluntary hospitals agitated for the government to pay all capital and excess expenditure in the proposed central hospital. The EHS Hospital Officer, Allen, vigorously supported the voluntary hospitals and informed government officials that an undercurrent of ‘anxiety and criticism’ existed in ‘hospital and medical circles’ towards the government.70 Tensions soon escalated over the government’s reluctance to fund the proposed scheme. Allen chastised the government’s inertia and parsimony and complained to the Ministry of Public Security that the administration was delayed by ‘observance of peace-time regulation’ which contradicted London’s ‘spirit’ and ‘attitude’ where the motto was: ‘get the job done’.

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Official reaction was symptomatic of the government’s general intransigence. The Ministry of Finance’s secretary W. B. Spender, renowned for his austere interwar economic policies, informed the prime minister that Allen was merely a ‘temporary officer’ in the government’s employment who had little acquaintance with the ‘principles of government administration’ and regarded any Treasury control as ‘irksome’.71 Spender was critical of Allen’s failure to provide a detailed estimation of the scheme’s potential cost and advised the government: I feel it would be dangerous for a technical officer to receive the very wide financial powers which Dr Allen seems to visualise as being entrusted to him, and if I am correct in this view I do not think the Ministry of Home Affairs officials would accord Dr Allen their support.72

Spender’s imperiousness reflected the long-held conservatism ingrained within Northern Irish officialdom. Growing public and political pressure coupled with increased strain on Belfast’s medical provision, however, forced the government to accede to the voluntary hospitals’ demands.73 The Purdysburn Emergency Central Hospital’s opening was delayed while the voluntary hospitals and government negotiated on bed numbers, patient transfer procedures and the civilian sick’s entitlement.74 The new hospital was finally opened in October 1942.75 Some Purdysburn patients were transferred to county mental institutions outside of Belfast demonstrating how the EHS further led to regional and coordination of services.76 The establishment of the EHS’s hospital demonstrated the strength of the medical profession in framing state medical services. It has long been viewed that social policy under the devolved Stormont administration was of secondary importance to the politics of constitutional and ethnic conflict; left–right politics had limited influence and policy was copied from London and implemented by ‘insiders’ including civil servants and professional interest groups.77 Such trends were partly evident in the establishment of the Northern Irish EHS which was overly influenced by the medical profession and modelled on London’s directions. The strength of Belfast’s voluntary hospitals in shaping the EHS, however, informs wider arguments regarding the dynamics surrounding health service reform in the 1940s. Much debate has prevailed on whether the United Kingdom’s NHS emerged from a broad consensus in favour of reform or the outcome of conflict between progressive forces in the form of the labour movement and more conservative and reactionary influences.78 The establishment of the EHS Central Hospital demonstrates the prevalence of the medical profession in health planning in Northern Ireland. This example lends credence to the importance of expert knowledge as a driver for change in the 1940s. Northern Ireland, however, was exceptional in a UK context making the projection of such findings onto the wider British picture problematic.

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EHS in Northern Ireland during the Second World War

The region’s weak labour movement and the Stormont administration’s lack of policymaking experience ensured that medical professional opinion had significant sway in shaping the region’s health service and especially its hospital services. This was also apparent in the establishment of the Northern Irish NHS where, unlike in Great Britain, boards of managements of former voluntary hospitals could maintain their endowments and disqualification of a doctor had to be made by a High Court judge and not the minister.79 It is incorrect, however, to dismiss the role of political and social pressure in shaping health service reform. The experience of the air raids had a deep impact on Northern Irish politics. The ineptness of the government’s response exposed a range of social problems and acted as a platform for growing discontent – within and outside Unionism – with the government cabinet and particularly Prime Minister Andrews, who was increasingly viewed as obdurately conservative, incompetent and eventually forced to resign.80 Dissent over wartime social and employment conditions threatened to bridge the political and religious divide and the Unionist Party suffered some by-election losses albeit to independent Unionist candidates. Such discontent was recognised by Allen during the debates on the central EHS hospital who warned the government of the ‘public outcry’ if the treatment of causalities, care of the sick, and welfare for the aged and infirm failed to meet demand.81 The labour movement also pressurised the government and in late 1941 the Northern Irish Labour Party MP, Jack Beattie, demanded that the EHS be extended to all citizens.82 Other labour movement activities included the call for integrated and extended health services in Belfast by the Socialist Medical Association (SMA). The SMA was influential in the expansion of health services in 1930s London Boroughs and also helped to forge popular support for Labour’s 1945 general election victory.83 While social discontent and the labour movement were important dynamics in Northern Irish society, the government often simply rejected out of hand the labour movement’s attempt to shape the EHS. This was evident in late 1943 when the Northern Irish Labour Councils sought a meeting with the Prime Minister, Basil Brooke, over the lack of hospital accommodation in Belfast. Brooke refused to meet the labour contingent stating that the voluntary hospitals were previously assisted through the establishment of the EHS Central Hospital. Brooke was unwilling to expand what was settled with the voluntary hospitals. Recent research into popular opinions towards health in Britain prior to the NHS argues that there was no great popular demand for radical change in health services although concern over geographical gaps in provision, hospital diet, conditions of long-stay patients in public hospitals and outpatient waiting lists existed.84 Employment and housing dominated at a popular level and health hardly got a mention.85 Similarly, Belfast’s social relations in the Second World War were marked by employment issues and housing. General social discontent undoubtedly checked any government insouciance on health,

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but the EHS was shaped to a much greater extent by the medical profession and civil servants, and policies adopted from London, than by pressure from the Northern Irish labour movement. Yet the EHS also brought changes in popular attitudes regarding access to health. Entitlement to the EHS – initially confined to members of the armed forces, air raid casualties and evacuated children – expanded as the war progressed. In May 1941 the EHS was extended to the aged, infirm, sick and women over seven months pregnant who were made homeless by air attacks. The mass evacuation of Belfast led to the extension of the EHS to evacuees in reception areas.86 Evacuees were also to receive assistance normally provided by local authorities such as maternity and child welfare.87 In 1942 the EHS was widened to include all workers in the wartime economy which followed Britain’s policy.88 This was important because Northern Ireland’s wartime economy grew substantially after initial inertia: the live register dropped from 71,410 in July 1940 to 14,687 in July 1944.89 Wartime contracts were received by companies such as the aircraft manufacturer Short Brothers whose workforce grew from 8,000 in 1941 to about 20,000 at the end of the war.90 Increased provision for wartime workers was not confined to hospitals and nursery centres for working women’s children were introduced.91 The expansion of entitlement to wartime provision helped forge expectations that such provisions would be maintained in any post-war society. The 1948 Health Services Act (Northern Ireland) nationalised most hospitals, with the Mater being the major exception, and placed them under the control of the Northern Ireland Hospitals’ Authority. This inaugurated a freeat-the-point-of-contact and universalist system funded by direct taxation across the United Kingdom. Northern Irish post-war planning for social services began in earnest, influenced by developments in Britain, in 1942 with the establishment of the Planning Advisory Board.92 A plethora of reports and investigations by hospital and health stakeholders, professional groups and government bodies proffered proposals for any reformed health system.93 The EHS played a key role within this milieu of debate and reform. Conclusion The experience of the EHS in Northern Ireland reveals much about 1940s health services and the dynamics underpinning reform. The EHS’s focus on regionalisation in many ways acted as a forerunner for the NHS. While regional and integrated health policies were somewhat evident in Northern Irish health, the EHS represented a radical departure in these directions. The EHS also had other important influences on Northern Irish health provision. The financing of health services in the local authority–Stormont–London axis was remodelled. Northern Ireland’s central government took over services traditionally viewed as the remit of local authorities and voluntarism while London accepted far

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EHS in Northern Ireland during the Second World War

greater financial responsibility for the health of the Northern Irish population. The leading role of the medical profession, especially the voluntary hospitals, in shaping the EHS also demonstrates that medical technocracy was highly influential in the region. This was particularly evident in the establishment of the EHS Central Hospital in which the demands of the voluntary hospitals were met while the concerns of the labour movement were discarded. The prominence of the medical profession in official decision-making can be partly explained by the lack of expertise in the Northern Irish government and the general weakness of labour politics, particularly in contrast to Great Britain. Yet wider social and political discontent surrounding wartime conditions were prevalent and ensured government action. The EHS (and ultimately the introduction of the NHS) in Northern Ireland was marked by a multitude of dynamics and interests which could be at times competing but also aligned. At a popular and everyday level, employment and housing issues trumped health service reform although the experience of the EHS, where large numbers were entitled to free health services for the first time, widened expectations of the role of the state while also diluting lingering poor law principles and paternal voluntarism. While much recent historiographical work has stressed the positive aspects of interwar health, the EHS still represented a significant expansion and progression in health services. In southern Ireland nothing similar to the EHS emerged and a universal system was never introduced. In turn, the 1940s can be viewed as a point when healthcare began to significantly demarcate in the two Irish states. Some similarities, however, continued to underpin both health services, especially the strength of the medical profession in shaping policy – this was most blatantly demonstrated in the south in the early 1950s when government plans for universal healthcare for mothers and their children were successfully resisted. The limited labour movements and weak central governments in both states, especially compared to Great Britain, accentuated the power of well-organised and powerful groups such as the medical profession. Notes   1  R. Titmuss, Problems of Social Policy (London: HMSO, 1950), pp. 487–501; C. Webster, The Health Services since the War Volume One: Problems of Health Care. The National Health Service before 1957 (London: HMSO, 1988); J. Stewart, ‘Healthcare systems in Britain and Ireland in the nineteenth and twentieth centuries: the national, international and sub-national contexts’, in D. S. Lucey and V. Crossman (eds), Healthcare in Ireland and Britain from 1850: Voluntary, Regional and Comparative Perspectives (London: Institute of Historical Research, 2015), pp. 76–7.   2  C. L. Dunn (ed.), The Emergency Medical Services, Volume Two: Scotland, Northern Ireland and Principal Air Raids on Industrial Centres in Great Britain (London: HMSO, 1953). The EHS has been outlined for some localities. See J. V. Pickstone, Medicine and Industrial Society: A History of Hospital Development in Manchester and Its Region, 1752–1946 (Manchester: Manchester University Press, 1985), pp. 296–9.

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Institutions and medical personnel   3  This historiography is extensive although the focus has mostly been on English and Welsh examples. For relevant recent work, see A. Levene, M. Powell, J. Stewart and B. Taylor, Cradle to Grave: Municipal Medicine in Inter-war England and Wales (Oxford: Peter Lang, 2011); B. M. Doyle, The Politics of Hospital Provision in Early Twentieth-Century Britain (London: Pickering & Chatto, 2014).   4  For an outline of differences between independent Ireland and Northern Ireland, see D. S. Lucey and V. Crossman, ‘Introduction’, in Lucey and Crossman (eds), Healthcare in Ireland and Britain. For controversies surrounding health service reform in independent Ireland, see E. McKee, ‘Church–state relations and the development of Irish health policy: the mother-and-child scheme, 1944–53’, Irish Historical Studies, xxv (November 1986), 159–94; R. Barrington, Health, Medicine and Politics in Ireland 1900–1970 (Dublin: Institute of Public Administration, 1987), chs 7–9; L. Earner-Byrne, Mother and Child: Maternity and Child Welfare in Ireland, 1920s– 1960s (Manchester: Manchester University Press, 2007). For an outline of modernday Irish health service, see M. M. Wiley, ‘The Irish health system: developments in strategy, structure, funding and delivery since 1980’, Health Economics, xiv (September 2005), 169–86.   5  P. Ollerenshaw, Northern Ireland in the Second World War: Politics, Economic Mobilisation and Society, 1939–45 (Manchester: Manchester University Press, 2013); L. McCormick, Regulating Sexuality: Women in Twentieth Century Northern Ireland (Manchester: Manchester University Press, 2009), especially ch. 5.   6  For public health, see L. McCormick, ‘Venereal diseases in Northern Ireland during the Second World War’, in M. H. Preston and M. Ó hÓgartaigh (eds), Gender, Medicine and the State in Ireland, 1700–1950 (New York: Syracuse University Press, 2012). For the establishment of the welfare state, see R. J. Lawrence, The Government of Northern Ireland. Public Finances and Public Services, 1921–1964 (Oxford: Oxford University Press, 1965), pp. 67–9; J. Ditch, Social Policy in Northern Ireland between 1939–50 (Aldershot: Avebury, 1988), pp. 90–128; A. Edwards, History of the Northern Ireland Labour Party: Democratic Socialism and Sectarianism (Manchester: Manchester University Press, 2009), pp. 22–4.   7  For a contemporary account, see L. Kidd, ‘A Ministry of Health for Northern Ireland’, Ulster Medical Journal, 5:4 (October 1938), 237–40; for a standard historical interpretation, see D. Harkness, Northern Ireland since 1920 (Educational Co. of Ireland: Dublin, 1983), p. 6.   8  For the mixed economy, see M. Katz and C. Sachße (eds), The Mixed Economy of Social Welfare: Public/Private Relations in England, Germany and the United States, the 1870s to the 1930s (Baden-Baden: Nomos, 1996); M. Powell (ed.), Understanding the Mixed Economy of Welfare (Bristol: Policy Press, 2007); S. Thompson, ‘The mixed economy of care in the South Wales coalfield, c.1850–1950’, in Lucey and Crossman (eds), Healthcare in Ireland and Britain.   9  Levene et al., Cradle to Grave; M. Gorsky, ‘Local government health services in inter-war England: problems of quantification and interpretation’, Bulletin of the History of Medicine, 85:3 (Fall 2011), 384–412; D. S. Lucey, ‘ “The schemes will win for themselves the confidence of the people”: Irish independence, poor law reform, and hospital provision’, Medical History, 58:1 (January 2014), 46–66. 10  Report on the Administration of Local Government Services for the Year 1st April to 31st March 1938 (Belfast: HMSO, 1939), p. 38. 11  In 1930, central government introduced a block grant system which protected it from any increase in local government public health costs. See Report of the Committee on the Financial Relations between the State and Local Authorities (Belfast: HMSO, 1931). 12  Gorsky, ‘Local government health services’, 410.

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EHS in Northern Ireland during the Second World War 13  S. L. Greer, Territorial Politics and Health Policy: UK Health Policy in Comparative Perspective (Manchester: Manchester University Press, 2004), pp. 159–66. 14  Greta Jones, ‘Captain of These Men of Death’. The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (Amsterdam: Clio Medica, 2001), p. 132. 15  In 1935/6 Belfast and Dublin Corporations expended 34.62 and 31.08 per 1,000 of population on maternity and child welfare compared to English and Welsh borough mean of 99.55. See Returns of Local taxation in N. Ireland, 1922–39; Levene et al., Cradle to Grave, pp. 68–71; Dublin City Archives, Dublin, Dublin Corporation Annual Report, 1937. 16  By 1940 Belfast had 3.27 beds per 1,000 of population compared to 2.31 in Sheffield, 2.49 in Liverpool and 4.56 in Dublin (D. S. Lucey and G. C. Gosling, ‘Paying for health: comparative perspectives on patient payment and contributions for hospital provision in Ireland’, in Lucey and Crossman (eds), Healthcare in Ireland and Britain, pp. 81–100). 17  M. Gorsky, J. Mohan with T. Willis, Mutualism and Healthcare: British Contributory Schemes in the Twentieth Century (Manchester: Manchester University Press, 2006). 18  Lucey and Gosling, ‘Paying for health’; M. E. Daly, ‘The curse of the Irish Hospitals’ Sweepstakes: a hospital system, not a health system’, History Hub: Working Papers in History and Policy, ii (2012), 9–11; M. Coleman, The Irish Sweep: A History of the Irish Hospitals Sweepstake 1930–87 (Dublin: Dublin University Press, 2009). 19  P. Martin, ‘Ending the pauper taint: medical benefit and welfare reform in Northern Ireland, 1921–39’, in V. Crossman and P. Gray (eds), Poverty and Welfare in Ireland, 1838–1948 (Dublin: Irish Academic Press, 2011). 20  These two groups within Ulster Unionism have been described as ‘populists’ and ‘anti-populists’ (P. Bew, P. Gibbon, and H. Patterson, Northern Ireland 1921–2001: Political Forces and Social Classes (London: Serif, 2002), p. 49). 21  Kidd, ‘Ministry of Health for Northern Ireland’, 229. 22  Public Record Office of Northern Ireland (hereafter PRONI), LA/7/3/C/14, ‘Report by Dr Thomas Carnwath on the Municipal Health Services of Belfast plus Responses to the Report by Various Committees’, 1941, p. 19. 23  PRONI, BG/7/A/125, ‘Belfast Board of Guardian’s Minute Book’, 6 January 1931. 24  F. F. Main, Our Health Services (Belfast, 1959), p. 3; Harkness, Northern Ireland since 1920, p. 6; A. Jackson, ‘Local government in Northern Ireland, 1920–73’, in M. E. Daly (ed.), County and Town: One Hundred Years of Local Government in Ireland (Dublin: Institute of Public Administration, 2001), p. 57, p. 60; Lawrence, Government of Northern Ireland, pp. 129–39. 25  PRONI, LA/7/3/C/14, ‘Report by Dr Thomas Carnwath’, p. 26; Nuffield Provincial Hospitals Trust, Survey of the Hospital Services of Northern Ireland (Belfast: Northern Ireland Regional Hospitals Council, undated), p. 5; Belfast Branch of the Socialist Medical Association, Health in Belfast: Facts, Figures and Recommendations Relating to the Health of the Citizens of Belfast (Belfast: Northern Ireland Labour Party, 1943), p. 4, p. 13. 26  B. Harris, The Origins of the British Welfare State: State and Social Welfare in England and Wales, 1800–1945 (Basingstoke: Palgrave Macmillan, 2004), p. 287. 27  D. M. Fox, ‘The National Health Service and the Second World War: the elaboration of consensus’, in H. L. Smith (ed.), War and Social Change: British Society in the Second World War (Manchester: Manchester University Press, 1986), p. 42. 28  N. Hayes, ‘Do we really want a National Health Service? Hospitals, patients and public opinions before 1948’, English Historical Review, cxxvii: 526 (June 2012), 625–61, 638.

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Institutions and medical personnel 29  R. M. Titmuss, History of the Second World War: Problems of Social Policy (London: HMSO, 1951), p. 62. 30  Northern Ireland House of Commons Debates, vol. 22 (18 April 1939), p. 955. 31  British Medical Association House (hereafter BMAH), London, ‘Minutes of British Medical Association Northern Ireland Branch’, 25 November 1937. 32  Ollerenshaw, Northern Ireland, p. 30. 33  BMAH London, ‘BMA Minutes’, 15 May 1939. 34  PRONI, CAB/9/CD/37/1/P/94, ‘McKewon to R. P. Pim, Cabinet Secretariat, Civil Defence, Stormont Castle’, 29 June 1939. 35  PRONI, CAB/9/CD/37/1/P/95, ‘Emergency Hospital Organisation: Extract from Memorandum by the Ministry of Home Affairs’, 5 September 1939. 36  PRONI, CAB/9/CD/37/1/P/83, ‘Ministry of Health, Whitehall to Pim’, 5 August 1939. 37  C. Webster, ‘Conflict and consensus: explaining the British health service’, Twentieth Century British History, 1:2 (February 1990), 115–51, 127. 38  PRONI, BG/23/P/3, ‘Ministry of Home Affairs Memorandum on Emergency Hospital Services’, 15 November 1939. 39  Titmuss, Problems of Social Policy, p. 76. 40  PRONI, CAB/9/CD/37/1/P/46–7, ‘Cabinet Memorandum on Dr Allen’, June 1941. 41  PRONI, CAB/9/CD/37/1/P/90, ‘Irwin to Holmes Cabinet Secretary’, 10 July 1939. 42  Northern Ireland House of Commons Debates, vol. 22 (4 September 1939), p. 1900. 43  ‘Emergency hospital service for Northern Ireland’, British Medical Journal, ii:1407 (23 September 1939), p. 189. 44  D. M. Fox, Health Policies, Health Politics: The British and American Experience, 1911– 1965 (Princeton: Princeton University Press, 1985). 45  Ibid, p. 28; S. Sheard, ‘The roots of regionalism: municipal medicine from the Local Government Board to the Dawson Report’, in Lucey and Crossman (eds), Healthcare in Ireland and Britain. 46  M. Gorsky, ‘The Gloucestershire extension of medical services scheme: an experiment in the integration of health services in Britain before the NHS’, Medical History, 50:4 (October 2006), 491–512; Gorsky, ‘ “Threshold of a new era”: the development of an integrated hospital system in Northeast Scotland, 1900–39’, Social History of Medicine’, 17:2 (August 2004), 247–67. 47  Webster, ‘Conflict and Consensus’. 48  M. Elliott, The Catholics of Ulster. A History (London: Penguin Books, 2001), pp. 458–64. 49  P. Martin, ‘ “Why have a Catholic Hospital at all?” The Mater Infirmorum Hospital Belfast and the state 1883–1972’, in Lucey and Crossman (eds), Healthcare in Ireland and Britain. 50  PRONI, CAB/9/CD/37/1/P/62, ‘A. Farrell to McKeown’, 5 August 1939. 51  D. Fraser, The Evolution of the British Welfare State, 3rd edn (Basingstoke: Palgrave Macmillan, 2003), p. 228. 52  Titmuss, Problems of Social Policy, p. 75. 53  PRONI, BG/23/P/4, ‘EHS Circular’, 26 November 1940. 54  PRONI, BG/23/P/2, ‘EHS Circular’, 30 April 1941. 55  ‘Emergency Hospital Service for Northern Ireland’. 56  A. S. MacNalty (ed.), The Civilian Health and Medical Services: Volume Two (London: HMSO, 1955), pp. 371–2.

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EHS in Northern Ireland during the Second World War 57  Report on Health and Local Government Administration in Northern Ireland during the Period 1st April 1938 to 31 December 1946 (HMSO: Belfast, 1948), p. 25. 58  Gorsky, ‘Local government health services in inter-war England’, p. 409. 59  ‘Emergency Hospital Service for Northern Ireland’, 190. 60  P. Buckland, The Factory of Grievances: Devolved Government in Northern Ireland, 1921–39 (Dublin: Gill & Macmillan, 1979), pp. 160–3. 61  PRONI, CAB/9CD/37/1/P/83, ‘Whitehall to Pim’, 5 August 1939. 62  National Archives, Kew (hereafter Kew), HLG7/427, ‘Wartime Services Expenditure – Northern Ireland, HC Chatfield, Ministry of Health to E. Hale, Treasury Chambers’, 16 August 1941. 63  Kew, HLG/7/427, ‘Wartime Services Expenditure – Northern Ireland, Hale to Chatfield’, 19 August 1941. 64  PRONI, BG/23/1, ‘EHS Circular’, 4 September 1939. 65  Dunn, Emergency Medical Services, p. 136. 66  For the Blitz, see B. Barton, The Blitz: Belfast in the War Years (Belfast: Blackstaff, 1989); S. Douds, The Belfast Blitz: The People’s Story (Belfast: Blackstaff Press, 2011). 67  Dunn, Emergency Medical Services, p. 136. 68  Ollerenshaw, Northern Ireland, p. 160. 69  PRONI, MIC514/1/1/24, ‘Royal Victoria Hospital Minute Book, Board of Management’, 23 April 1941. 70  PRONI, CAB/9/CD/37/1/P/38, ‘Purdysburn Reserve Hospital, Allen’, 25 July 1941. 71  For an outline of Spender’s career, see P. Maume, ‘Spender, Sir Wilfrid Bliss’, in Dictionary of Irish Biography. 72  PRONI, CAB/9/CD/37/1/P/35, ‘Purdysburn Reserve Hospital, W. B. Spender to PM’, undated. 73  PRONI, CAB/9/CD/37/1/P/32, ‘Purdysburn Reserve Hospital’, August 1941. 74  PRONI, MIC514/1/1/24, ‘Royal Victoria Hospital Minute Book, Board of Management’, 15 April 1942. 75  PRONI, MIC514/1/1/24, ‘Royal Victoria Hospital Minute Book, Board of Management’, 7 October 1942. 76  PRONI, CAB/3/A/59, ‘Professor Crymble ‘The Influence of the European War on Surgery in Northern Ireland, Northern Ireland War History. File No. 12 Medical Health Services Act’, undated. 77  Greer, Territorial Politics and Health Policy, p. 161. 78  This historiography is extensive, key works include Webster, ‘Conflict and consensus’. For a brief outline, see M. Gorsky, ‘The British National Health Service 1948–2008: a review of the historiography’, Social History of Medicine, 21:3 (December 2008), 441–3. 79  Ditch, Social Policy, p. 99. 80  Edwards, History of the Northern Ireland Labour Party, pp. 22–4. 81  PRONI, CAB/9/CD/37/1/P/38, ‘Purdysburn Reserve Hospital, Allen’, 25 July 1941. 82  Northern Ireland House of Commons Debates, vol. 24 (12 November 1941), pp. 2233–4. 83  J. Stewart, The Battle for Health: The Political History of the Socialist Medical Association (Aldershot: Ashgate, 1999); J. Stewart, ‘ “The finest municipal hospital service in the world”? Contemporary perceptions of the London County Council’s hospital provision, 1929–39’, Urban History, 32:2 (August 2005), 327–44. 84  Hayes, ‘Do we really want a National Health Service?’. 85  Ibid., 641. 86  PRONI, BG/23/P1–16, ‘EHS Circular: Payment in Respect of Casualties’, 23 May 1941.

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Institutions and medical personnel 87  PRONI, BG/23/P1–16, ‘EHS Circular, Health and Welfare Services in Reception Areas’, 25 June 1941. 88  PRONI, MIC/514/2/12, ‘Royal Victoria Medical Staff Minutes’, 13 January 1942. 89  J. W. Blake, Northern Ireland in the Second World War (London: HMSO, 1956), p. 537. 90  Ollerenshaw, Northern Ireland, p. 108. 91  G. McIntosh, ‘ “Who’s looking after the baby?” Nursery school care in Northern Ireland during the Second World War’, in G. McIntosh and D. Urquhart (eds), Irish Women at War (Dublin: Irish Academic Press, 2010). 92  Ditch, Social Policy, p. 72. 93  Northern Ireland Regional Hospitals’ Council, The Red Book: A Plan for Hospital Services of Northern Ireland (Belfast: Northern Ireland Regional Hospitals Council Provincial Bank House, 1946); Nuffield, Survey of the Hospital Services of Northern Ireland; Belfast Branch of the Socialist Medical Association, Health in Belfast.

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12

Imperial continuities: Irish doctors and the British armed forces, 1922–45 Steven O’Connor Previous contributions in Part III of this book have examined the impact of the First World War on institutions and medical personnel working on the Irish domestic front. In contrast, this chapter examines the recruitment and experiences of Irish medical personnel serving in the British armed forces after Southern Ireland attained independence in 1922. Since the 1860s Irish doctors had been significantly over-represented in the medical services of the British Empire. At the turn of the twentieth century Ireland comprised only one-tenth of the United Kingdom’s population. Yet the island accounted for much larger proportions of the recruits to the Army Medical Service, the Royal Navy’s medical service and the Indian Medical Service.1 This disproportionate Irish share continued after 1922 in spite of Southern Ireland seceding from the United Kingdom. Between 1922 and 1945 the island of Ireland accounted for 23.6 per cent of the recruits to the permanent ranks of the Royal Army Medical Corps (16.4 per cent from the Irish Free State and 7.2 per cent from Northern Ireland), which was almost triple Ireland’s share of the population of the British Isles.2 Moreover, this contribution to British military medicine was exceptionally high in comparison with Ireland’s contribution to the rest of the British Army: from 1905 to 1913 and again from 1919 to 1921 Ireland provided about 9 per cent of the recruits to the enlisted ranks of the army – a proportion which declined steadily in the decade following independence.3 This chapter examines the reasons behind the imperial continuity in the recruitment of Irish doctors to the British forces. The origins of this recruitment to the British forces lay in a wider medical emigration out of Ireland due to the inability of a predominantly rural and shrinking population to absorb the large number of Irish medical graduates. From the mid-nineteenth century onwards the sons of upwardly mobile families were increasingly attracted to the income prospects and social status of the

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medical profession, which meant that Irish universities expanded unevenly and became dependent on the medical school for much of their revenue. Hence they routinely produced many more medical graduates than could be employed in Ireland and the majority settled in Britain or its Empire. There was plenty of demand for general practitioners in the industrial towns of Britain. Those with money or family connections could set up a private practice or buy into an existing one. However, for Irish medical graduates lacking money or connections, or those that were adventurous, the pay, pension entitlement, permanent employment and opportunities for travel of medical service with the British armed forces could be more attractive than the insecure and often underpaid work of an assistant to a practice or a dispensary medical officer in a poor district of Britain or Ireland.4 To explain why this recruitment continued after 1922, this chapter examines the evidence of the Irish recruits’ social backgrounds and motivations as derived from a sample. The sample comprises 401 Irish-born medical officers who obtained a commission in the British Army, Navy, Air Force or in the Indian Medical Service (which provided medical support to the British forces in India) between 1922 and 1945. It embraces the whole range of medical officers which composed these services including nurses, veterinarians and dentists but it is predominantly made up of doctors. The sample has been mainly gathered from Sir Robert Drew’s roll of officers in the Royal Army Medical Corps5 (RAMC), the records of the Army Medical Services Museum, Aldershot, British Medical Journal, Irish Journal of Medical Science, Ulster Medical Journal and the annuals of several prominent schools. The sample is divided into interwar and wartime cohorts in order to compare recruitment patterns during these two periods. The analysis encompasses the two states established in Ireland by 1922: the Irish Free State (a self-governing British dominion, renamed Ireland or Éire in 1937) and Northern Ireland (which had a measure of self-government but remained under the overall control of the UK government). For the sake of clarity the former state is often referred to as ‘Southern Ireland’ throughout the chapter. The interwar period It is curious that Irish medical graduates during the interwar period continued to regard military medicine as offering a rewarding career. In general the interwar period represented a low point for the British military medical services as they were plagued by spending cuts and recruitment problems. Proposals for reforming the RAMC, in order to attract more young doctors to the service, were shelved in 1922 when the British government decided to reduce military spending: the RAMC’s peacetime establishment was reduced from 1,062 officers to 945 and there would be no more attempts to improve pay or terms of service for over ten years.6 Astonishingly, in spite of Southern Irish

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Irish doctors and the British armed forces

secession from the United Kingdom and the unpopularity of military medicine in Britain, the proportion of Irish recruits to the RAMC actually increased. Collating the place of birth of medical officers in Drew’s roll of the RAMC indicates that between 1923 and 1933 (after which date the recruitment system was substantially reformed), England provided only 35.5 per cent of the recruits while comprising 78.4 per cent of the population of the British Isles. Meanwhile, the two Irish states were still enormously over-represented: the Irish Free State comprised 6.1 per cent of the British Isles’ population but accounted for 21.5 per cent of the recruits to the RAMC and Northern Ireland comprised only 2.5 per cent of the population while providing 10.2 per cent of the recruits.7 This gives a total for the island of Ireland of 31.7 per cent, representing an increase on the Irish proportion between 1900 and 1914 (29.1 per cent).8 In 1931 the Warren Fisher Committee sought to address the perceived shortcomings of a career in British military medicine. It proposed to reduce the number of regular officers but to increase the number of higher posts, which would improve the rate of promotion. It also recommended recruiting officers on short-service commissions to rectify any deficiency. Following the implementation of these proposals in 1934 recruitment began to improve. Forty-two short-service commissions were granted and most of these officers eventually applied for a permanent commission.9 According to the sample, Irish medical recruitment began to rise significantly in 1933. It is likely that the economic depression in Ireland, exacerbated by the ‘Economic War’ with Britain, was the driving factor. Moreover, the commencement of rearmament in 1934 – when the British Army was allotted £20 million primarily to increase its peacetime establishment – saw Irish numbers joining the RAMC rise steadily for the remainder of the 1930s.10 This was in direct contrast to the small number of British doctors coming forward for commissions. Thus overall the RAMC continued to experience shortages and as late as 1939 it was 210 medical officers short of the establishment authorised by the War Office. This situation was only remedied by the introduction of limited conscription in April 1939.11 In the sample there are 154 medical officers from the Irish Free State who obtained a commission during the interwar period. Unsurprisingly, in terms of social origins they were predominantly from the middle classes. The educational background of 44.4 per cent of the interwar cohort is unknown but 48.3 per cent had attended a boarding school, while only 7.3 per cent went to a day school. Moreover, the father’s occupation is known for ninety-nine officers (or 64 per cent of the cohort). Of these 32.4 per cent were the sons of university-educated professionals, such as solicitors, engineers and doctors (doctors alone accounted for 22.2 per cent of the fathers’ occupations), the fathers of 12.1 per cent were farmers, 10.1 per cent were company directors or managers and 9.1 per cent were civil servants (see Table 12.1). Explicit links to the ancien régime were evident among only 12.1 per cent of the fathers’

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Institutions and medical personnel Table 12.1  Father’s occupation in interwar cohorts

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Occupation

Professional Merchant Company manager Farmer Clergyman Civil servant Shopkeeper Skilled labour Military officer Other

Southern Ireland

Northern Ireland

%

%

32.4 6.1 10.1 12.1 8.1 9.1 4 4 3 11.1

16.6 4.8 11.9 14.3 7.1 2.4 14.3 4.8 2.4 21.4

Source: S. O’Connor, Database of Irish medical officers in British forces (1922–45)

occupations: three were British Army officers, five were members of the Royal Irish Constabulary and four were clerks in the Dublin Castle administration. An examination of the officers’ birthplaces reveals that counties Dublin and Cork were significantly over-represented: Dublin accounted for 37.7 per cent of the medical officers and Cork for 18 per cent, yet the same counties comprised respectively 17 per cent and 12.5 per cent of the Free State’s population. This over-representation could be explained by the concentration of the middle classes in large urban areas. The remaining 45 per cent of officers were evenly distributed among a large number of counties. Turning to Northern Ireland, the sample contains fifty-one medical officers from the six counties who joined between the wars. The father’s occupation is known for forty-two officers and in social background they differed slightly from the south: only one father was a civil servant, farmers and shopkeepers accounted for 14.3 per cent each, 11.9 per cent were company managers and professionals were marginally better represented with 16.6 per cent. The majority came from Belfast and other towns. Considering that Northern Ireland had a proportionally high Protestant community, it was perhaps unsurprising that Protestants dominated with 74.5 per cent of the recruits while Catholics represented 11.8 per cent. This contrasts with the Free State where Catholic enthusiasm for the imperial medical services was markedly higher: 52.6 per cent of the interwar recruits were Catholic and 42.8 per cent were Protestant. What did Irish medical officers put forward as their reasons for joining the British forces? Few medical officers who joined up during the interwar period left a record of their motives. Air Commodore Aidan MacCarthy from Cork

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Irish doctors and the British armed forces

was driven to take a commission by a mixture of professional pragmatism and the lure of adventure. After qualifying he lacked the money to do a postgraduate course, which was becoming more and more necessary to obtain a dispensary post in Southern Ireland. Consequently he decided to look for medical work in Britain. By early 1939 he grew dissatisfied with his job in a London surgery and opted to take a short-service commission in the Royal Air Force (RAF). He was quickly disappointed by the ‘seaside suburbia’ that was his first posting: ‘at this point, bad as it may sound, I was actually looking forward to the war’.12 He went on to win the George Medal for selfless bravery in rescuing aircrew from a burning plane and later spent three years in Japanese captivity. Another recruit who joined up in early 1939 was Brigadier General Desmond Murphy from Wexford. He did not record his reasons for joining the RAMC other than to say that he was ‘filled with the youthful enthusiasm of a twenty-five year old’.13 This may suggest a desire for adventure. The exodus of doctors from Ireland MacCarthy and Murphy were part of the annual emigration of medical graduates to Britain due to the lack of employment in Southern Ireland. Unlike their predecessors before 1922 their decision to emigrate now involved crossing national borders. However, there were no legal restrictions on the movement of labour between the two islands and Irish medical schools were still represented on the General Medical Council of the United Kingdom and subject to its periodic inspections. Indeed, there were other striking continuities with the pre-1922 period. The attachment of the Irish middle classes to medicine did not abate. During the interwar period Irish medical schools continued to produce a disproportionate amount of the first-year entrants to medical schools in the British Isles. Revealingly, in 1936 the island of Ireland made up only 8.6 per cent of the population of the British Isles but 20.4 per cent of the first-year medical registrants.14 This packing of the medical schools fuelled medical emigration. A survey by Greta Jones of 540 Irish doctors (from both north and south) who graduated between 1920 and 1940 suggests that about 39 per cent of Irish medical students who graduated between the wars had to make a living outside of Ireland, with the majority of emigrants (94 per cent) securing either civil or military posts in Britain or its colonies.15 This was a reality well understood by those young Irish people who chose the profession. As Michael Flynn related: There was no prospect of employment for me in Ireland at the time as only those graduates who passed the final examination with first or second class honours obtained posts of house surgeon (HS) in teaching hospitals, mine having been the Mater Hospital, Dublin … it was an established pattern for decades that surplus Irish medical graduates went to England.16

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The aforementioned Aidan MacCarthy, who joined the RAF in 1939, gave another perspective on Irish medical emigration. He believed that the medical graduates’ difficulty in finding work in Ireland was ‘because all specialised appointments were controlled by local medical professional nepotism, and the jobs were very limited in number … the result was that nearly eighty per cent of newly qualified doctors had to cross the water to England and Wales, where medical work was plentiful, particularly in the armed services’.17 Indeed, corruption in medical appointments was a serious problem in Southern Ireland. Hospital management was quite often a family affair and, as MacCarthy mentioned, there was a large degree of inbreeding when it came to recruitment for specialised positions. Similarly, dispensary doctors were appointed to office following an election by the County Board of Health. This frequently became the occasion for the exercise of patronage and sectarianism. In 1924 two local politicians in Monaghan were convicted of attempted bribery for demanding money from applicants for such a post. This corruption drove the government to set up an independent Local Appointments Commission in 1926, to ensure that candidates for local appointments would be judged on their professional merits and not on their family connections, religion or willingness to bribe. According to Mary E. Daly, this reform largely eliminated corruption in public medical appointments.18 The main cause of the exodus from Ireland was MacCarthy’s second reason – the small number of medical jobs. In 1942 the Irish Journal of Medical Science carried an article about the prospects for medical graduates, written by the president of the Royal College of Surgeons in Ireland, A. Ffrench-O’Carroll. He echoed MacCarthy’s belief that the majority of graduates ‘must seek their careers in Britain or elsewhere’. The president observed that on average 290 graduates were qualifying in Southern Ireland each year and he calculated that the country could ‘absorb only approximately seventy doctors per annum, of whom twenty-two will be dispensary medical officers, ten full-time appointments and the balance private practitioners or specialists’.19 Writing in The Bell two years later Earl McCarthy, a lecturer in University College Cork’s medical school, pointed out that per capita of population Southern Ireland produced many more medical graduates than England–Wales, Belgium, Poland, Norway and Hungary and that only Scotland and Northern Ireland produced more. He suggested that this over-production originated as ‘a response to the wide opportunities offered by affiliation with an empire’. However, McCarthy noted that after seven years of teaching at University College Cork the majority of his former students were no longer resident in Ireland and concluded that ‘the large scale of export of medical ability to Britain seems a bleak illogicality viewed against the background of Irish national aspiration’.20 In his article McCarthy identified one of the key attractions of medical service with the British forces. The most common posts open to young Irish doctors in Britain were assistantships and locum tenens; if a doctor wanted a

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Irish doctors and the British armed forces

better position, he or she needed lots of savings or a bank loan, in order to buy a practice or enter into a partnership. As McCarthy explained, ‘medical service in the British Forces has afforded an escape hitherto from the initial encumbrance of bank overdrafts, and has attracted Irish doctors in great numbers’. The attraction for many Irish doctors was that the air force, the navy and later the army operated a system of short-service commissions during the interwar period. Under this system, as Air Commodore Eric Lumley from Tullamore wrote, ‘a number of young doctors would come into the Flight Lieutenant ranks and after serving four or five years would retire with some useful experience and a generous gratuity to help in starting a practice’.21 Therefore, the above contemporary sources suggest that the lack of jobs in Ireland for the large surplus of medical graduates led many to emigrate to Britain, where some grew dissatisfied with typical entry-level posts and decided to join the British forces. Crucially, the system of short-service commissions offered a strong incentive for military service among Irish medical graduates who desired to open their own practice but lacked the financial means – the gratuity on completion of five years’ service could help them realise this goal. ‘A union of hearts’? It would be an oversimplification to assume that Irish medical emigration to Britain was governed purely by economic considerations. A survey by University College Dublin’s student newspaper in 1946 found that 76 per cent of second- to final-year medical students believed they would have to emigrate after graduating, while 63 per cent of the students surveyed said, if given the choice, they actually preferred to emigrate than work in Southern Ireland.22 Thus, medical students were keenly aware of the attractive opportunities for working abroad. This outward-looking attitude, particularly towards Britain and its Commonwealth, was a reflection of the myriad of long-standing personal, academic and professional networks linking the British and Irish medical communities. In 1933, the Irish-born president of the British Medical Association (BMA) referred to the 1867 annual meeting of the BMA which was held in Dublin: ‘the meeting was a symbol of a union of hearts between members of the medical profession in Great Britain and Ireland, a union which in spite of political changes and developments, has never since been broken and remains steadfast to-day’.23 A few weeks before his speech the National University of Ireland had decided to confer an honorary degree on, among others, Dublin native Colonel Hugh Rigby. He had led a prestigious medical career in Britain, which included service in the RAMC during the First World War and an appointment as the sergeant-surgeon to George V from 1928 to 1932. It was in this latter role that Rigby performed the operation which saved George V’s life in 1928.24 The conferral was clear recognition of the contribution of Irish doctors to Britain, but it was also a reaffirmation of the close ties

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between doctors in the two countries at the same time as the Anglo-Irish ‘Economic War’ began its course.25 As well as symbolic gestures there were concrete expressions of this connection: after 1922 the Southern Irish medical schools remained part of the British regulatory body, the General Medical Council; in 1933 the BMA held its annual meeting in Southern Ireland where the Association had 1,000 members; in 1936 the Irish Medical Association and the Southern Irish branches of the BMA fused to form the Irish Free State Medical Union (IFSMU) with BMA membership privileges extended to the Union’s members; even the Irish Medical Students’ Association was affiliated and worked closely with the British Medical Students’ Association.26 The close ties between the Irish and British medical communities clearly informed the career advice and expectations of medical graduates’ destinations emanating from the Irish medical establishment. In the 1930s Irish universities assumed that many doctors would consider emigrating upon graduation and the advice given to prospective medical students reflected this likelihood, with British military service routinely put forward as a sound choice. In 1937, the IFSMU was upbeat: ‘It remains true that only a limited number of doctors can be absorbed annually into practice, private and institutional, in the Saorstat, but the number is greater than formerly, whilst the demand for Irish medical men in Great Britain, both in general practice and in the Services, shows no signs of saturation.’27 In Belvedere College’s annual for 1939 E. Freeman similarly advised pupils of the school that the majority of medical graduates interested in general practice would have to move to Britain and spend some years working as an assistant to a practice. On the other hand, he pointed out that ‘a large number of Irish graduates enter the military services of Great Britain’. He proceeded to outline the system of short-service commissions, explaining that those officers who chose to leave after five years received a gratuity of £1,000. Freeman concluded: ‘This system aims at a certain number of permanent officers in the higher ranks and at a larger number of junior officers who leave the service and do not therefore seek promotion in it. In this way, the man who makes it his life’s work has greater opportunity of reaching higher rank and has a higher compulsory retiring age.’28 The self-evident benefits of British service were then contrasted with the shortcomings of the Irish equivalent. Freeman asserted that ‘the Irish Army Medical Service is not attractive. Prospects of promotion are slight. Hospitals are dreary and the pension scheme is inadequate.’29 This view was even more forcefully expressed by the IFSMU which strongly advised ‘the younger members of the profession to refrain from seeking or accepting commissions in the Army Medical Service of Ireland while conditions of that Service remain as they are’,30 and even warned medical students against joining university detachments of the Volunteer Force, in case they were drafted for medical service with the regular army.31 Frank Aiken, the Minister for Defence, had provoked the Union’s ire by ignoring its advice and introducing budgetary

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Irish doctors and the British armed forces

measures in 1937 and 1938, which significantly reduced pay and pension entitlements. Medical officers recruited under the new pay scale would earn 50 per cent less than under the previous system while existing officers could retain their old salary but would not receive an increase on promotion, regardless of increased responsibilities. The Union failed to dissuade Aiken from implementing these measures and it concluded with exasperation that: ‘The present conditions are not such as to attract young men of even mediocre ability and are certain to deter young men of the type the army ought to set itself to get.’32 Therefore, it is significant that in their advice to youngsters who were considering taking a degree in medicine and to medical graduates themselves, the IFSMU and other commentators expressed a preference for the British military medical services over the Irish one during a period when war was becoming increasingly likely. The Second World War Considering the large scale of both Irish medical emigration to Britain and ongoing Irish recruitment to British military medicine, it is unsurprising that Irish doctors played an active role in the Second World War. Turning first to the sample, it appears that Southern Irish medical officers recruited during the war generally came from the same social backgrounds as during the interwar years (see Table 12.2). The sample contains 141 wartime recruits: 58.2 per cent of this cohort was Catholic, 54 per cent were educated at a boarding school, many of their fathers had farming, business or professional interests and Dublin remained by far the main source of medical officers with 37.6 per cent.

Table 12.2  Father’s occupation in wartime cohorts Occupation

Professional Merchant Company manager Farmer Clergyman Civil servant Shopkeeper Skilled labour Military officer Other

Southern Ireland

Northern Ireland

%

%

31.3 1.6 6.2 17.2 4.7 10.9 7.8 4.7 4.7 10.9

31.4 9.8 5.9 11.8 5.9 3.8 7.8 11.8 – 11.8

Source: S. O’Connor, Database of Irish medical officers in British forces (1922–45)

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However, there were also some signs of social mobility in the cohort: the fathers of two medical officers were shoemakers and another was a carriage smith. Social mobility was also evident in the Northern Ireland wartime cohort of fifty-five officers. The father’s occupation is known for fifty-one officers and 11.8 per cent were skilled labourers. Nevertheless, the largest portion was professionals (31.4 per cent) and Protestants were still predominant with 78.2 per cent of the cohort. An examination of the date of commission in the wartime cohorts suggests that Irish recruitment to the British military medical services surged from 1939 to 1940 and then gradually declined; by 1944 recruitment was returning to the smaller numbers seen in the 1930s.33 The reason for this can best be explained by examining motives in the cohort. Similar to Irish officers in other branches of the British forces, Irish medical officers who joined up for war service usually had multiple reasons for doing so.34 Though Richard Barry grew up in Cork, he believed the fact that his mother was English influenced his decision. Moreover, there was a family tradition; both his grandfathers and an uncle had served in the British Army. Finally, Barry had been working in hospitals around London since he had qualified in 1937 and not only did he agree with Britain’s war aims, but he also felt that he owed a certain allegiance to his host country: I don’t know if you can talk about a just war, but if there was one I thought that the war against the Germans overrunning Europe was justifiable, especially led by Hitler, and then I felt also that you can’t go to England and get jobs there, which I did after I qualified … and then when England gets into difficulties not lend a hand to help her.35

This sense of duty to the country that had provided him with employment opportunities explains why there was a large spike in medical officer recruitment in the first sixteen months of the war. The pace of recruitment had been growing rapidly since 1938 but data from the sample suggests that this accelerated after the outbreak of war: the last four months of 1939 accounted for 13 per cent of the Southern Irish medical personnel commissioned during the war, a relatively high rate of recruitment continued during 1940 when onequarter of the total war recruits were commissioned. This spike is too large to be explained solely by the regular intake of newly qualified Irish doctors into the British forces, which seemed to peak in 1938.36 The additional numbers coming forward for service in the first sixteen months of the war must largely have been Irish doctors, like Barry, who had been able to settle in Britain during the 1930s by securing employment in hospitals or private practices. A similar trend occurred in Northern Ireland. James Pantridge, who had only recently graduated and had been appointed a house physician at the Royal Victoria Hospital, Belfast, on 1 August 1939, went to the recruiting office with his colleagues the day after war was declared, although owing to his lack

Irish doctors and the British armed forces

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of hospital experience he had to wait until April 1940 before being called up. Out of the thirteen ‘housemen’ at his hospital, Pantridge recalled that eleven joined up. Pantridge was awarded a Military Cross for his bravery during the fall of Singapore and spent over three years in Japanese captivity.37 Ian Fraser, who joined the RAMC as a captain in 1939 and finished the war as a brigadier general, had studied medicine at Queen’s University, Belfast after the First World War and remembered the atmosphere: When I went to the university nearly half of my year were ex-servicemen, and hearing the chat of these men I and those of my age could not fail to develop inferiority complexes. I wished that I had done more … with the threat of war in 1939 I threw my hat into the ring and offered to go, but without really thinking much about it. I never felt I looked much like a soldier, but I had an underlying feeling that I must do something.38

Many others must have felt like Pantridge and Fraser as the majority of the Northern Ireland wartime cohort joined up in 1939 or 1940. There were additional motives among Irish wartime doctors. Andy Parsons from Athlone decided to take a commission in the RAMC believing that he would gain a considerable amount of professional experience, which would be denied to a civilian. Yet the prospect of adventure was also a big attraction: when Parsons was serving in North Africa with a regiment that was about to be sent to Tobruk, he fell ill with jaundice and ‘was bitterly disappointed at missing this chance of seeing a bit more action’.39 However, Parsons later received plenty of opportunities for action in both North Africa, where he earned the Military Cross for gallantry, and in the Italian campaign, where he was wounded while serving in the Anzio bridgehead. Majella, a nurse from Kildare, explained that she went to Britain during the war because there were plenty of jobs there in comparison with Ireland. Yet, she also joined the reserve of the Queen Alexandra’s Imperial Military Nursing Service. After ten months of working in a civilian hospital she was called up for service. Like Parsons her motive for volunteering was the appeal of adventure: she thought the war would be over in a year and she was eager ‘to get into it before it ended’. As a young person during the war, she explained, ‘the only thing you’re thinking about is where you’re going to go and all the excitement that goes with it’.40 The sharp reduction in Irish medical recruits from 1941 onwards, effectively returning to the numbers of the 1930s, would suggest that the supply of resident Irish doctors and nurses had been exhausted by then and that Irish recruitment was now solely being sustained by the usual flow of surplus medical graduates from Ireland.41 Although the Irish Army’s medical service recruited many doctors in the early years of the Emergency, there remained a surplus of medical graduates some of whom went to Britain to replace general practitioners and hospital surgeons serving in the British forces. In their turn,

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these doctors faced the prospect of being conscripted for military service if they worked in Britain for longer than two years. Nevertheless, even these recruits can be considered voluntary as they had the right to return to neutral Southern Ireland rather than accept the call-up. Not all graduates were attracted to the employment prospects in wartime Britain; the journal of the IFSMU suggested another reason for the drop in recruits when it noted in May 1941 that, ‘at the moment we have a very considerable body of unemployed young doctors in Ireland’ and that ‘many of them have been persuaded by their parents or friends not to proceed abroad during the war’.42 In terms of the career success of medical officers from Ireland, there was a natural swing in favour of the interwar cohort; these officers were more likely to have joined the services for a permanent career, whereas most wartime medical officers left the armed forces after the war. The average length of service for a Southern Irish interwar recruit was twenty years (although 25.8 per cent served for thirty years or more) and 62.3 per cent of these recruits retired with a middle rank of their respective service, such as lieutenant colonel, surgeon commander or squadron leader, which would be expected for a career medical officer. The figures for the Northern Ireland interwar cohort were similar: on average they served for twenty-two years and 51 per cent retired with a middle rank. However, medical service with the British forces was not without its difficulties. The rate of attrition among Irish medical officers (north and south combined) from 1922 to 1945 was 27.4 per cent: five officers resigned their commission, one was court-martialled, eighty-three died on active service and twenty were invalided out of the service due to illness. Of the latter category it is worth noting that most had spent many years serving in India or the Far East where they had probably suffered from the same diseases that they were sent to treat. Indeed, even in peacetime there was a significant fatality rate among Irish medical officers: between 1930 and 1937 four officers from Northern Ireland and one from Southern Ireland died in Asia. Interestingly, from the interwar cohort 17 per cent of the Southern Irish and 27.5 per of the Northern Irish reached senior rank (brigadier general, rear admiral, air vice marshal or above) after the Second World War. This created the unusual situation where the Irish had a strong presence in high command at the same time as Southern Ireland left the British Commonwealth and established itself as a republic in 1949. For example, in the early 1950s Air Marshal James Kilpatrick from Belfast was Director General of RAF Medical Services and Surgeon Rear Admiral Seymour Rainsford, a Dublin native, was the Deputy Director General of the Royal Navy’s Medical Service. This legacy continued into the 1960s with several of the top medical posts being held by Irish men: Lieutenant General Harold Knott from Leitrim was Director General of Army Medical Services (1961–65), Cork native Major General Henry Quinlan was Director of the Army Dental Service (1958–63), Surgeon Vice Admiral Eric Bradbury from Tyrone was the Royal Navy’s Medical Director

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Irish doctors and the British armed forces

General (1969–71) and Air Vice Marshal Cecil Beamish from Derry was Director of the RAF Dental Service (1969–73). In spite of the transfer of political power to Dublin after the Anglo-Irish Treaty of December 1921 and the successful assertions of the sovereignty of the Irish state during the 1920s and 1930s, old assumptions and practices survived. In the spheres of economics, defence and popular culture great reliance continued to be placed on Southern Ireland’s nearest neighbour.43 Not only was Britain expected to be the largest buyer of Irish agricultural exports but it was also expected to provide a home for Irish workers who could not find employment in their own country.44 Doctors were particularly affected by this emigration due to Irish medical schools persistently producing far more medical graduates than were needed in Ireland. For those graduates with ambition and those simply seeking a stable income and reasonable standard of living Britain was a logical choice based on the easy access to the labour market, cultural and linguistic affinities, similar work practices and plenty of employment opportunities. Once in Britain the majority of the doctors found employment in general practice. Though the numbers joining the British armed forces declined from its peak in the nineteenth century, the Irish continued to be significantly overrepresented. Given the difficultly of recruiting British doctors for the military medical services, why should this be the case? The evidence from medical officers and contemporary commentators in Ireland suggests that the introduction of short-service commissions helped to sustain Irish enthusiasm. It provided four or five years of secure employment after which some doctors left the service and used the gratuity to make a start in general practice, while others decided that they enjoyed the lifestyle or believed they had good career prospects and remained. During the Second World War many Irish doctors who were already working in Britain and others who had recently graduated in Ireland joined up. As with other Irish wartime recruits their motives varied from loyalty, peer pressure and family tradition to idealism, a desire for adventure and many other factors. However, the two cohorts – interwar and wartime – while different were united by a common thread. Indeed, what is remarkable about the significant presence of Irish doctors in the British forces during the 1930s and 1940s is not that it indicated the continuation of pre-1922 economic trends but that it illustrated the enduring personal, professional and academic ties between the Irish and British medical communities, which thrived independently of the strained and often heated relations between the Irish and British governments. Notes   1  S. O’Connor, Irish Officers in the British Forces, 1922–45 (Basingstoke: Palgrave Macmillan, 2014), pp. 85–7.

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Institutions and medical personnel   2  S. O’Connor, Database of Irish medical officers in the British forces (1922–45).   3  D. Fitzpatrick, ‘Militarism in Ireland, 1900–1922’, in T. Barlett and K. Jeffery (eds), A Military History of Ireland (Cambridge: Cambridge University Press, 1996), p. 380, p. 502f.   4  See G. Jones, ‘ “Strike out boldly for the prizes that are available to you”: medical emigration from Ireland 1860–1905’, Medical History, 54:1 (January 2010), 55–74.   5  R. Drew, Commissioned Officers in the Medical Services of the British Army 1660–1960, Volume Two: Roll of Officers in the Royal Army Medical Corps 1898–1960 (London: Wellcome Historical Medical Library, 1968).   6  M. Harrison, Medicine and Victory: British Military Medicine in the Second World War (Oxford: Oxford University Press, 2008), pp. 13–7.   7  O’Connor, Database of Irish medical officers.   8  Nelson Lankford, ‘The Victorian medical profession and military practice: army doctors and national origins’, Bulletin of the History of Medicine, 54:4 (December 1980), 511–28, 528.   9  O’Connor, Irish Officers, p. 96. 10  O’Connor, Database of Irish medical officers. 11  Harrison, Medicine and Victory, p. 30. 12  A. MacCarthy, A Doctor’s War (London: Robson, 1979), p. 15. 13  Clongownian (1993), p. 15. 14  Jones, ‘Medical emigration’, 68–9. 15  Ibid., p. 57, p. 70. Table detailing destinations of interwar cohorts provided to the author by Professor Greta Jones. 16  M. Flynn, Medical Doctor of Many Parts (Dublin: Kelmed, 2002), p. 4. 17  MacCarthy, Doctor’s War, p. 11. 18  M. E. Daly, ‘Local appointments’, in Mary E. Daly (ed.), County and Town: One Hundred Years of Local Government in Ireland (Dublin: Institute of Public Administration, 2001), pp. 46–50. 19  A. S. Ffrench-O’Carroll, ‘When you qualify’, Irish Journal of Medical Science, 17.11 (November 1942), 575–90, 589. 20  E. McCarthy, ‘Eire’s surplus doctors’, The Bell, 9:2 (November 1944), 119–28, 120. 21  E. Lumley, Army and Air Force Doctor (London: Leo Cooper, 1971), p. 119. 22  National Student (May 1946), pp. 6–7. 23  Irish Independent (26 July 1933), p. 10. 24  Irish Times (21 July 1944), p. 3. 25  The fraternal feeling was mutual. In 1941 the RAMC responded to a request for penicillin from the Irish Army medical service, supplying the drug and offering to send a pathologist who specialised in its administration (T. McKinney, ‘Ireland’s army medical service’, in W. Doolin (ed.), What’s Past Is Prologue (Dublin: Monument Press, 1952), pp. 38–9). 26  ‘Ireland’, British Medical Journal, i (25 March 1933), 532; ‘Annual report of council, 1934–5’, British Medical Journal, i (20 April 1935), 154; ‘Ireland’, British Medical Journal, i (29 February 1936), 433; National Student (December 1945), 62. 27  R. Rowlette and J. Flood, ‘Editorial: medicine as a career’, Journal of the Irish Free State Medical Union, 1:3 (September 1937), 27. 28  E. Freeman, ‘The medical profession’, Belvederian (June 1939), 45–8, 47. 29  Ibid. 30  Anon., ‘The army medical service’, Journal of the Irish Free State Medical Union, 4:19 (January 1939), 76–7. 31  Anon., ‘The army and the medical student’, Journal of the Irish Free State Medical Union, 4:20 (February 1939), 18. 32  Anon., ‘Army medical service’, 76–7.

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Irish doctors and the British armed forces 33  O’Connor, Database of Irish medical officers. 34  See O’Connor, Irish Officers, chs 1–3. 35  Barry quoted ibid., p. 99. 36  O’Connor, Database of Irish medical officers. These proportions differ from an earlier attempt to analyse Irish medical recruitment owing to a much larger sample being used here (O’Connor, Irish Officers, pp. 99–100). 37  J. Pantridge, An Unquiet Life (Belfast: Greystones Books, 1989), pp. 11–13. 38  I. Fraser, Blood, Sweat, and Cheers (Cambridge: British Medical Journal, 1989), p. 33. 39  A. Parsons, Exit at Anzio (privately published), p. 49. 40  Majella, quoted in O’Connor, Irish Officers, p. 102. 41  O’Connor, Database of Irish medical officers. 42  Anon., ‘Doctors and the war’, Journal of the Irish Free State Medical Union, 8:42 (May 1941), 55–6. 43  On Southern Ireland’s attachment to British popular culture, see S. O’Connor, ‘The pleasure culture of war in independent Ireland, 1922–45’, War in History, 22:1 (January 2015), 66–86. 44  A dependency which became much stronger in the 1930s after economic depression and increased restrictions on immigration made America a less attractive destination, see E. Delaney, Demography, State and Society: Irish Migration to Britain, 1921–1971 (Liverpool: Liverpool University Press, 2000), pp. 43–5.

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Migrants, medics, matrons: exploring the spectrum of Irish immigrants in the wartime British health sector Jennifer Redmond There is a significant lacuna in British and Irish narratives of the Second World War: the experiences of Irish citizens in Britain. Why is this significant? Irish men and women contributed to the British war front effort on the home front in large numbers and experienced all the deprivations, challenges and dangers that this entailed. Their history has yet to be told and their contributions have not been recognised in the major histories of Churchill’s stoic Britain or de Valera’s neutral Ireland. Many histories of the war have ignored the fact that Irish people already in Britain and those who migrated during the conflict staffed factories, transportation and medical services that desperately needed their labour, or that their children were evacuated along with their British counterparts to other parts of Britain and back to Ireland. They made aircrafts, uniforms, parachutes, produced essential foodstuffs, joined the postal and clerical positions opened up by the war, and, most importantly, Irish men and women cared for the sick, the dying and the dead throughout Britain, including the heavily bombed areas of central London. Irish men and women who served in the armed forces have received more recent attention, and are discussed by Steven O’Connor in Chapter 12 in this volume, but the civilian population’s contribution is in need of further research.1 Similar to the liminality of Irish people in the cultural imagination surrounding the Second World War, migration history has been dominated by narratives of unskilled workers. Granted, unskilled work was the majority experience for Irish migrants over the last two centuries: domestic service for women, navvying or unskilled labouring for men. Even in the immediate post-war period Irish-born men in unskilled work outnumbered those in professional and technical professions by three to one, for example.2 However, this does not represent the totality of Irish migrant experience. Skilled, educated workers, including doctors, nurses and other health professionals, were also

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Irish immigrants in the wartime British health sector

part of the flow from Ireland and deserve to be recorded, particularly for their contributions during the war. Indeed, Enda Delaney has cautioned against the narrow labelling of the Irish diaspora as having a homogeneous identity, recognising the complex and somewhat ambiguous relationship the diaspora can have with the idea of Ireland as homeland.3 Mary E. Daly has made a similar point, urging us to recognise the temporal, experiential, geographical and class differences between women migrants from Ireland.4 Furthermore, recent trends in Irish migration historiography have also emphasised the importance of Britain in the twentieth century as a destination, away from the primacy of post-Famine migration to America.5 This chapter continues that focus by analysing an under-represented group in the historical literature. It adds to both the historiography of the social history of medicine and to that of the Irish diaspora by tracing those Irish working in the British medical sector during the Second World War. Elsewhere I have termed this ‘Ireland’s medical diaspora’, referring to ‘the dispersal of Irish-trained or Irish-born migrants working as doctors, nurses or other kinds of medical professionals throughout the world in the nineteenth and twentieth centuries’.6 Although female nurses have featured in recent historiography, the full panoply of their expertise and experience has yet to be sketched, and the wider spectrum of Irish people working in British hospitals and institutions is only beginning to emerge.7 This chapter examines both men and women and argues for the greater visibility of their contribution during the war. Irish people were there, in the hospitals, on the home front, risking their lives to save others; their story deserves to be told. Medical migration is a topic identified by Greta Jones and Elizabeth Malcolm as warranting serious scholarly attention in the field of Irish medical history in their 1999 collection Medicine, Disease and the State in Ireland, 1650– 1940.8 Although some significant work has since been conducted, this has not focused exclusively on medical migrants. Rather, the trend has been to include emigration as a common result of medical training, particularly for doctors, due to a lack of available appointments in Ireland. Furthermore, while it is well known that Irish women migrated to nursing in Britain, their contributions during the Second World War have remained relatively unexamined – the focus often being on the need for their contributions in light of the introduction of the National Health Service. Histories thus far have been partial, and while this chapter cannot claim to trace the entire history of the Irish contribution to the medical sector during the war period, it does give a more holistic picture, including doctors and nurses side by side instead of separately. The lack of attention to this group of migrants is partly explained by the difficulty of accessing relevant source material. Indeed, it is difficult to trace emigration in the post-independence period due to the scant nature of extant documentation. This is particularly the case in relation to Britain, where

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emigrants, or travellers, were not required to inform authorities, apply for visas or carry identification on their journeys for most of the twentieth century. The one exception is the period from 1940 onwards during the Second World War when travel permits were needed for journeys between Britain and Ireland due to security concerns as a result of the conflict (apart from those in the security forces who did not need to carry them).9 The information derived from these permits was used extensively by the Commission on Emigration and Other Population Problems (1948–54) in their attempt to categorise and understand migration flows in the context of continuous population decline.10 This chapter draws on the applications for return, either permanent or temporary, of Irish citizens in Britain, a resource hitherto unavailable to researchers.11 Of the applicants, 15,252 (66.2 per cent) were women and 7,788 (33.8 per cent) were men. In addition, 4,378 children were found to be part of the applications. The larger cohort of women can be explained by a few factors: they were more likely than men to be evacuating children, a large proportion of women did not work outside the home and thus had the ability to travel, and the large number of nurses in the files; over one-fifth described themselves as state-registered nurses. Nurses often had their travel paid for by employers and were more likely to be guaranteed holidays than other kinds of workers by British hospitals to diminish fatigue. In the case of travel permit applications from medical migrants, 4,625 cases were found of Irish men and women working in the British medical field.12 A brief profile of the cohort will be given prior to a more detailed discussion of the categories of nurses and doctors. Although this chapter cannot explore the experiences of the other groups who also risked their lives in first-aid nursing at air raid shelters, driving ambulances and providing auxiliary services such as radiography or pharmacy, it is hoped that further research into this area will reveal, and thus credit, those who did this important work that sustained hospitals in crucial ways. The largest number of applications to return to Ireland were made in the spring and summer of 1941, with the highest proportion (841 or 18.2 per cent) coming in July, followed closely by June (765 or 16.6 per cent) and May (702 or 15.2 per cent). This correlates with the most intense period of fighting during the Battle of Britain between July 1940 and May 1941 and perhaps suggests that medical personnel were taking a break after intense work during this period. Applicants could be found in seventy-seven different locations throughout England, Scotland and Wales, but in common with the general profile of the cohort, the greatest concentration of applicants were in London or its environs, again testifying to the desire by applicants to flee the total war conditions. Thus 1,102 applicants (23.8 per cent) were in London city, with 447 (9.7 per cent) living in Surrey, 367 (7.9 per cent) in Kent, 229 (5.0 per cent) in Essex and 174 (3.7 per cent) in Middlesex at the time of application.13 Scarcer numbers of applicants were in remote parts of Wales and Scotland, an

Irish immigrants in the wartime British health sector Table 13.1  Occupations of Irish citizens in the British medical field

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Occupation

Nurse (state-registered nurse/staff nurse) Nurse (probationer) Specialist nurse Nurse assistant Doctor Ward sister Private nurse Maternity ward nurse/midwife/pupil midwife Air Raid Protection/Civil Nursing Reserve/First Aid/Red Cross Matron Religious in nursing Ambulance driver First Aid Post worker Orderly Ambulance attendant Nurse companion Dentist Radiographer Pharmacist Total

Number

Percent (%)

3,141 743 160 124 105 90 68 47 38 22 19 13 12 12 10 9 5 5 2 4,625

67.9 16.1 3.5 2.7 2.3 1.9 1.5 1.0 .8 .5 .4 .3 .3 .3 .2 .2 0.5 0.5 .0 100.0

Source: National Archives of Ireland, Department of Foreign Affairs, Travel Permit Files

unsurprising finding given the propensity of Irish migrants to conform to Ravenstein’s theory that migrants usually go to urban areas.14 As Table 13.1 reveals, the profile of the cohort was diverse, with a mix of hospital based, trained professionals and those working in private care or more directly on the home front in first aid or ambulance driving.15 The range of occupations listed in Table 13.1 reveal a diverse picture of the employment of Irish people during the Second World War in British hospitals, institutions and homes. Those with professional qualifications such as nurses, doctors and dentists have been included alongside orderlies, ambulance attendants and nurse companions to demonstrate the range of occupations, although it must be noted that they are not all of equal professional or remunerative stature. This relatively small cohort of people applying for travel permits leads to the question: how many more Irish people who did not apply for travel permits in the period 1940 to 1942 were also working in similar roles? While any answer is necessarily speculative, it seems possible to suggest that there were many more. The point remains that Irish people contributed in many varied ways to the British home front effort through their work in the medical field.

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Institutions and medical personnel Table 13.2  Occupations of Irish men in medical-related professions

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Occupation Doctor Nurse (SRN/staff) First Aid Post worker Nurse (specialist) Nurse (assistant) Religious in nursing Ambulance driver Dentist Orderly Pharmacist Ambulance attendant Nurse (probationer) Total

Number 93 36 9 8 5 5 4 3 2 2 1 1 169

Percent (%) 55.0 21.3 5.3 4.7 2.95 2.95 2.4 1.8 1.2 1.2 .6 .6 100.0

Source: National Archives of Ireland, Department of Foreign Affairs, Irish Travel Permit Application Files

The gender divide in the profile of this group conforms to expectations: the majority of nurses were women (3,105 or 69.7 per cent of the female cohort) and the majority of doctors (ninety-three or 55 per cent of the male cohort) were men, although noteworthy is the small numbers of male nurses and female doctors. Table 13.2 gives the breakdown of male applicants by occupation, and Table 13.3 gives the same for females. There are small numbers of both male (five) and female (fourteen) religious in nursing, a reminder of the involvement of religious orders in the medical field beyond Ireland. Irish people going to work in British hospitals in the war would have faced tough conditions and personal danger, particularly as the majority were based in the Greater London area. The Medical Press and Circular of the period gives ample descriptions of the difficulties of life in hospitals, particularly in the London region that was heavily affected by bombings by the Luftwaffe.16 The bravery shown by all levels of staff is attested to in this publication, as is their resilience in straitened circumstances as they attempted to continue their work in makeshift wards and in air raid shelters. Irish nurses were at the front line in many instances, and some paid with their lives for their dedication. Nurses Irish female nurses occupied a prominent position in the twentieth-century British healthcare sector, particularly during and after the Second World War, although the demand for their labour had existed for decades before, as

Irish immigrants in the wartime British health sector Table 13.3  Occupations of Irish women in medical-related professions

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Occupation Nurse (SRN/staff) Nurse (probationer) Nurse (specialist) Nurse (assistant) Nurse (ward sister) Private nurse Nurse (maternity ward/midwife/pupil midwife) Nurse (ARP/Civil Nursing Reserve/First Aid/Red Cross) Nurse (matron) Religious in nursing Doctor Orderly Ambulance attendant Ambulance driver Nurse companion Radiographer First Aid Post worker Dentist Total

Number

Percent (%)

3,105 742 152 119 90 68 47 38 22 14 12 10 9 9 9 5 3 2 4,456

69.7 16.7 3.4 2.7 2.0 1.5 1.1 .9 .5 .3 .2 .2 .2 .2 .2 .1 .1 .0 100.0

Source: National Archives of Ireland, Department of Foreign Affairs, Irish Travel Permit Application Files

highlighted by Anne Mac Lellan who has sketched the need for Irish labour in the British health sector from the 1920s to the 1950s, particularly for tuberculosis nurses.17 Indeed, ‘it was found by the Wood Committee in 1946, that twelve per cent of the total hospital nursing staff was born in Éire’.18 Irish women joined others from former and current colonies in the war and postwar period to meet the gap left by British women who perceived it as ‘a poorly paid and less attractive occupation’, according to Yeates.19 Migration was attractive to women in nursing as the profession was becoming overcrowded in Ireland in the 1930s. In 1936 the Irish Nurses’ Organisation asked all general and maternity hospitals to temporarily limit the number of candidates they were taking due to unemployment among nurses, although later in the 1930s there was a shortage of midwives while there was still an over-supply of nurses.20 This continued into the 1940s, with the Irish Nurses’ Organisation giving evidence to the Commission on Emigration and Other Population Problems that just 10 per cent of graduate nurses were likely to be employed by their training institution in Ireland.21 Concomitantly, a persistent shortage of nurses in Britain led to openings across the hospital sector for trained and untrained Irish women. The joint register meant that nurses could have their

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qualifications recognised in both countries. Hence, as I have argued elsewhere, there was a dynamic relationship between the British and Irish medical systems in the exchange of nurses.22 On the basis of this evidence, it may be argued that the female equivalent of the Irish male emigrant archetype in Britain, the Irish navvy, is the young Irish nurse, in contrast to the earlier prevalence of Irish women domestic servants in America ubiquitously known as ‘Bridget’.23 Irish women were particularly targeted for recruitment to Britain through nursing journals and it seems that a variety of women took up the opportunity, from those already qualified in search of better wages and conditions, to those seeking training, particularly women who could not afford the expense of training in Ireland.24 Both Protestant and Catholic nurses were recruited to the system; a distinction based on religious affiliation was not a prominent feature of British recruitment, although a religious tone existed nonetheless in many hospitals. The Church of Ireland Gazette, for example, cautioned its clergymen readers to warn girls not to go to hospitals run by nuns due to the high pressure imposed upon probationers to convert.25 Conversely, Catholic girls were warned not to accept positions in hospitals that would not allow them to practise their religion by attending mass regularly.26 Despite this position in popular imagination, they have not featured as prominently in histories of nursing in Britain. Brian Abel Smith’s seminal work, A History of the Nursing Profession, makes just one brief mention of Irish nurses despite the fact that it discusses shortages in nursing and the strategies used to fill vacancies, including improvements in terms and conditions, the establishment of a secondary grade of nursing assistants and the introduction of the National Health Service.27 It is well known that Irish women, trained and untrained, were used to fill gaps in the British medical field, yet the only mention of ‘foreign’ nurses is to those trained and registered outside of Britain. I have argued elsewhere that there is a historical myopia about the contribution of Irish women to the British war effort in munitions and factory work, and here it seems that the myopia exists almost wilfully in excluding an aspect of Irish diasporic history that is more visible than many of the employment roles that Irish women held.28 The scant reference to the significant minority of Irish nurses does not do justice to the importance of this career for Irish female emigrants nor to their service during the war. Praise for the fortitude of nurses in London hospitals during the Blitz was published in the Medical Press and Circular in 1943, and although it drew on stereotypical, and perhaps romanticised, notions of duty and vocation in female nurses, it did illuminate and praise their courage during the hostilities: ‘this high conception of their calling which in peace time finds expression in a nurse’s cheerful devotion to duty, explains why in war time she will unhesitatingly shield her patients, if need be with her own body’.29 Research in Irish journals reveals cases of Irish women involved in front-line efforts during the Blitz that attest to their bravery and in some instances reveal the fatal

Irish immigrants in the wartime British health sector

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consequences of being part of Ireland’s wartime medical diaspora. The Irish Nursing and Hospital World proudly reported that: Great courage was displayed by Sister Agnes Magovern, a native of Bailieborough, Co. Cavan, when the hospital in London, of which she was assistant matron, was hit by a bomb and partially demolished, four wards being destroyed and the walls ripped open. Although seriously injured, Sister Magovern continued to direct operations in the hospital. The majority of the patients had been removed only a few hours previously. Sister Magovern is now making progress towards recovery.30

However, the same issue also reported the fatality of two young Irish nurses: Emily Palmer aged 21 and originally from Kenmare, Co. Kerry, a nurse in a London hospital who was fatally injured during an air raid, and Patricia Magee, a 19-year-old from Armagh, who died from injuries she sustained during an air raid at St John’s Wood, London, where she was employed as a children’s nurse.31 The travel permit application records reveal thirty-six men who identified themselves as nurses and one man who termed himself a nurse probationer, although, by the regulations at the time, men were not referred to as nurses for the most part but were often termed orderlies or attendants. It is difficult to ascertain from the information on these forms how much training they had in comparison with their female counterparts but it seems that the institutionalised sexism towards them may obscure their qualifications and experience. Like female doctors, they represent a very small minority within the overall cohort, but it is interesting to speculate whether the opportunity to nurse in Britain, denied to them in Ireland, was a motivation for emigration.

Doctors Recent trends in the history of medicine in Ireland have moved away from the study of ‘institutions or famous doctors, in the same way that historians of medicine in Britain did prior to the 1980s which, as Laura Kelly has observed, had previously dominated the field ‘at the expense of wider themes within the social history of medicine in Ireland’.32 The migration of Irish doctors has a long history, longer than that of nursing. Jones has found that between the mid-nineteenth and mid-twentieth centuries, 41 per cent of Irish-trained doctors were practising outside the country a decade after their training.33 Speaking of the pre-independence era in Ireland, Kelly has found that it was uncommon for Irish women doctors to migrate to the traditional anglophonedestination countries such as Australia, the United States and Canada, arguing that this ‘suggests there were ample opportunities for women medical graduates within the United Kingdom’.34 Indeed, in tracing these women graduates,

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Kelly has found that most were either in England (36.8 per cent, thirty-five years after graduation) or Ireland (47.9 per cent).35 This demonstrates that akin to other emigrants, female medical graduates were drawn to England in high numbers in the post-independence era. They were joining a very small rank of female professionals, however. By 1911 there were just forty-two female practitioners in Ireland36 with 477 registered female doctors in Britain37 which had risen by just 160 women fifty years later.38 Women doctors graduating after the First World War had more limited work opportunities than graduates of previous generations, thus the option to migrate to Britain, and more specifically to England, may have appealed more greatly to them. It was felt that the profession was overcrowded by the 1920s but with the concomitant rise in opportunities in Britain due to the expanding public health sector and hospitals, women with Irish medical degrees found jobs there, being more likely than their Irish-based counterparts to work in this area, although as Kelly stipulates, this was due to increased opportunities rather than direct discrimination in Ireland.39 Of the 105 doctors, eighty-five were able to be traced through the Medical Directory and all but two had completed their training in Ireland. Of this group, twelve qualified in Trinity College Dublin; fifty-four through the National University of Ireland (NUI, the particular college is not stated in the directory);40 fifteen had joint qualifications through the Royal College of Surgeons in Ireland and the Royal College of Physicians of Ireland; and three others, one having completed training in Aberdeen, one with a joint National University of Ireland and Royal College of Physicians Society in Ireland and one having completed training in both Britain and Ireland. The majority gave their current addresses (as of 1941) in Britain. This confirms the findings of Jones and Kelly that the United Kingdom remained a consistent emigration destination for doctors trained in Ireland. For those that gave current addresses in Ireland, it is possible that they interpreted this as asking about permanent residence. The average age of the doctors in this cohort was 35, suggesting some years of professional practice after graduation, although the youngest applicant was aged 23 and the oldest was 68. Thus, the sample included both ends of the career spectrum from beginning to end. The permits required women to state their marital status, thus we know more about this aspect of the group for women than men. Kelly’s work has found that women doctors were likely to marry fellow doctors41 and this appears to be the case for this group of doctors. Of the four married women doctors, all had Irish-born husbands. The marital status of men is revealed in some of their qualitative responses explaining their purpose of journey which reveals both the evacuation of children and visiting wives and children already evacuated to Ireland. This reason is not limited to doctors but is given by applicants across the range of occupations, although it must be noted that the most common reason for return (given by

Irish immigrants in the wartime British health sector

72.8 per cent of the medical migrants), akin to the wider cohort, is simply for a holiday, to reconnect with loved ones and visit their place of birth. There are glimmers of the war context highlighted by the applications: the mention of needing rest from work or illness, and more strikingly, one doctor who stated he was travelling to apply to the Irish Army.42

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Conclusion Irish adults and children in Britain during the war occupied an anomalous and much misunderstood position, being, to reappropriate Bronwen Walter’s phrase, ‘outsiders inside’, and furthermore, being a large minority of nationals of a neutral country living in a belligerent one.43 In fact, some only entered Britain at the onset of war, and war as a motivating factor for migration to rather than from a place is an unusual (but not exceptional) phenomenon in historical migration flows. Irish men and women in the British medical field occupied the full spectrum of roles and contributed much during the Second World War, yet we know little of their histories. The cultural imagination and memory of the conflict has solidified around the history of Irish neutrality, ignoring the substantial contributions of Irish citizens who either lived in Britain or who went there to ‘do their bit’ or find employment. We must also consider, however, that Irish medical migrants may have participated in their own ‘forgetting’ in historical narratives; their invisibility may have been a strategy of assimilation or conformity, the ‘result of ‘ethnic fade’ in middle-class Irish immigrant communities, a strategy employed to avoid discriminatory attitudes’.44 This may have also been impacted by sensitivities due to Ireland’s neutral status. I have raised the question elsewhere of whether or not this proved problematic for Irish nurses and doctors treating wounded British soldiers and civilians.45 The paucity of oral or biographical source material from such migrants means this remains a question. Through the analysis of travel permit application files, a detailed picture of applicants in this field wishing to return to Ireland emerges. Irish citizens occupied the full range of jobs in the health sector, from nurses to midwives, radiologists to dentists. This history offers a glimpse into stories both known and unknown: for while there is a general awareness that the oversupply of medical professionals in Ireland was historically absorbed by Great Britain and its Empire, little has been written on this particular kind of migration in comparison to other categories of migrants, such as navvies, domestics and religious. The British medical field offered opportunities unavailable to the overcrowded, smaller health sector in Ireland for doctors and nurses as well as other health professionals. In the post-war period, with the advent of the National Health Service, such opportunities continued to expand; by 1951, for example, there were 21,672 Irish born women and 880 men working as trained nurses

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and midwives in Great Britain (11 per cent of the total profession for women, 4.6 per cent for men) and 637 female and 4,111 male Irish born doctors (9.5 per cent and 11.4 per cent of the total respectively).46 In the post-war period Irish women were actively recruited, although some had their reservations about this trend. The authors of the Working Party on the Recruitment and Training of Nurses Minority Report published in 1948 called attention to problems in the running of hospitals, stating that: ‘this is exemplified in the staffing of hospitals with Irish or Baltic girls, a method which, like the importing of continental labour for other occupations, however desirable for short-term purposes, cannot be a lasting solution’.47 The easy availability of suitably aged Irish women, however, meant that they continued to serve in British institutions, and were recruited in particular alongside women under twenty-five, part-time nurses, married women and men to deal with acute shortages experienced by some hospitals.48 Demand for Irish graduate doctors remained steady in Britain, but the post-war period also saw an increase in their migration to America, increasing the sphere of the Irish medical diaspora in the late twentieth century.49 The extent of this medical diaspora is only now being sketched, and further work is needed to create a fuller understanding of the class, education and professional diversities within Irish migrant flows across the twentieth century. Contemporaries noted the trend for graduate doctors to emigrate with unease, for while the Commission on Emigration and Other Population Problems simply observed that ‘the majority of those who qualify find it necessary to seek a livelihood abroad’, others interpreting the trends were made more uncomfortable by the exodus of a stronghold of Ireland’s middle class.50 Spencer’s unpublished report in 1960 reflected on the Commission’s earlier observations, but lamented that Ireland was losing ‘her most valuable sons and daughters, her university graduates and professional men, and the enterprising, go-ahead men who find no scope for them at home’.51 We cannot know the full extent of Irish people’s contribution through their medical work to the home front effort, but this chapter has argued that Irish people, men and women, were part of this history. Many could have chosen to work in less dangerous professions, particularly during the worst phases of the Battle of Britain which saw daily civilian casualties and threats to central London hospitals. Although their contributions have not been adequately remembered and celebrated as yet, it is important to recall that Ireland’s medical diaspora assisted in saving many lives. Quite simply, the evidence reveals one simple truth: they were there. Notes   1  The contribution of Irish people during the Second World War is covered in E. Delaney, Demography, State and Society: Irish Migration to Britain 1921–1971

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Irish immigrants in the wartime British health sector (Liverpool: Liverpool University Press, 2000) among other publications primarily focused on emigration, not particularly on the migrant experience in Britain during the war. For examination of the issue of neutrality, see C. Wills, That Neutral Island: A History of Ireland during the Second World War (London: Faber and Faber, 2008) and B. Evans, Ireland during the Second World War: Farewell to Plato’s Cave (Manchester: Manchester University Press, 2014). For recent treatments of Irish participation in the British Army, see B. Kelly, Returning Home: Irish Ex-Servicemen after the Second World War (Dublin: Merrion Press, 2012); S. O’Connor, Irish Officers in the British Forces, 1922–45 (Basingstoke: Palgrave Macmillan, 2014).   2  A. E. C. W. Spencer, Arrangements for the Integration of Irish Immigrants in England and Wales (Dublin: Irish Manuscripts Commission, 2012). Information is taken from Table 11 on p. 39: Men in ‘Unskilled not elsewhere specified’ work as classified by the 1951 Census numbered 35,583 in comparison to those in ‘professional and technical’ category who numbered 14,828.   3  E. Delaney, ‘The Irish diaspora’, Irish Economic and Social History, 33 (December 2006), 51–8.   4  M. Daly, ‘Irish women and the diaspora: why they matter’, in D. A. J. MacPherson and M. Hickman (eds), Women and Irish Diaspora Identities: Theories, Concepts and New Perspectives (Manchester: Manchester University Press, 2014), p. 4.   5  For my own discussion of Irish women’s experience of working in twentiethcentury British hospitals, see J. Redmond, ‘The thermometer and the travel permit: Irish women in the medical profession in Britain during World War Two’, in MacPherson and Hickman (eds), Women and Irish Diaspora Identities. The contribution in this collection expands my analysis to men and offers new conclusions on the Irish experience of the war.   6  Redmond, ‘The thermometer and the travel permit’, p. 93.   7  One of the most recent examples is A. Mac Lellan, ‘Victim or vector? Tubercular Irish nurses in England, 1930–1960’, in C. Cox and H. Marland (eds), Migration, Health and Ethnicity in the Modern World (Houndmills: Palgrave Macmillan, 2013). The work of Louise Ryan, particularly her oral history work with Irish nurses in Britain is a further exception. See L. Ryan, ‘Migrant women, social networks and motherhood: the experiences of Irish nurses in Britain’, Sociology, 41 (April 2007), 295–312 and ‘ “I had a sister in England”: family-led migration, social networks and Irish nurses’, Journal of Ethnic and Migration Studies, 34 (2008), 453–70.   8  G. Jones and E. Malcolm (eds), Medicine, Disease and the State in Ireland, 1650–1940 (Cork: Cork University Press, 1999), pp. 4–5.   9  Permits were issued at an office in Dublin for travel from there and when in Britain Irish applicants had to apply to the Irish High Commission. 10  Report of the Commission on Emigration and Other Population Problems (Dublin: Stationery Office, 1954); National Archives of Ireland (hereafter NAI), DFS 14249/ Annexe. 11  The collection of permit applications is held by the National Archives of Ireland in their Department of Foreign Affairs collection. It is an incomplete set of records covering the years c.1940 to 1942, comprising over 23,000 applications. As part of an Irish Research Council Postdoctoral Fellowship (2009–11), a database of the information from these files was created by the author. The files were transferred at an unknown date from the Irish Embassy in London to the National Archives of Ireland where they are open, but uncatalogued. The collection is understood to have been damaged in the 1950s due to flooding (information provided to the author by Dr Michael Kennedy, Royal Irish Academy). 12  See Table 13.1 for descriptions of job categories which I define as being in the ‘medical field’.

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Institutions and medical personnel 13  Middlesex was absorbed into Greater London as part of the Local Government Act 1963 so no longer exists as a separate geographic location but it has been retained here for historical accuracy. 14  D. B. Grigg, ‘E. G. Ravenstein and the “laws of migration” ’, Journal of Historical Geography, 3 (January 1977), 41–54, 42–3. 15  Job titles were taken from the descriptions given by the applicants themselves. In some instances, such as ‘specialist nurses’, smaller groups were collated into one category. Specialist nurses included paediatric nurses and tuberculosis nurses, for example, while it was thought convenient to collate nurses who specified they worked on maternity wards with those who described themselves as midwives or trainee midwives. 16  The Medical Press and Circular was an incorporation of the journals hitherto known as the Medical Press and the Medical Circular. This publication was examined for the period 1939 to 1945. 17  Mac Lellan, ‘Victim or vector?’. 18  B. Abel Smith, A History of the Nursing Profession (London: Heinemann, 1960), p. 215. 19  N. Yeates, ‘A dialogue with “global care chain” analysis: nurse migration in the Irish context’, Feminist Review, 77 (August 2004), 79–95, 86. 20  The increased emigration of Irish nurses throughout the 1930s led to a shortage of nurses in Ireland in the 1940s. For a thorough exposition of the situation, see P. Scanlan, The Irish Nurse: A Study of Nursing in Ireland: History and Education, 1718–1981 (Manorhamilton: Drumlin Publications, 1991). 21  Trinity College Dublin Manuscripts Department, Arnold Marsh Papers, 8307–8/11. ‘Evidence submitted by Miss Healy (President), Miss Grogan (Secretary) and Mrs Nix (Member of the Executive) on behalf of the Irish Nurses’ Organisation’, 14 January 1948. 22  Redmond, ‘The thermometer and the travel permit’, p. 100. 23  See for example, M. Lynch-Brennan, The Irish Bridget:  Irish Immigrant Women in Domestic Service in America, 1840–1930 (New York: Syracuse University Press, 2009). A further example is the dust-jacket image for E. Delaney, The Irish in PostWar Britain (Oxford: Oxford University Press, 2007). The top three awardees of the British Nurse of the Year awards in 1964 appear – all were Irish. 24  Scanlan argues that probationers were required to give an entrance fee, but the amount was not standardised across different hospitals and some abandoned the fee due to a shortage of nurses after the First World War (Irish Nurse, p. 103). Furthermore, as Abel Smith outlines, local authority hospitals in Britain took in higher numbers of students without secondary education, a requirement for entry in the nursing profession in Ireland (History of the Nursing Profession, pp. 274–5). 25  Church of Ireland Gazette (3 October 1947), p. 14. 26  The International Catholic Girls’ Protection Society, for example, issued regular warnings in the Irish Catholic to girls taking up work in Britain to ensure that they would have time off to go to Mass. 27  Abel Smith, History of the Nursing Profession. 28  J. Redmond, ‘The largest remaining reserve of manpower: historical myopia, Irish women workers and World War Two’, Saothar, 36 (2011), 61–70. 29  A. J. M. Tarrant, ‘Moorfield’s Eye Hospital in the “Blitz” ’, Medical Press and Circular, 210:3 (20 January 1943), 52–5. 30  ‘Irish Nurse’s Courage’, Irish Nursing and Hospital World, 10 (10 October 1940), 2. 31  ‘Two Nurses Killed’, ibid., 16. 32  L. Kelly, Irish Women in Medicine, c.1880s–1920s: Origins, Education and Careers (Manchester: Manchester University Press, 2012), p. 5.

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Irish immigrants in the wartime British health sector 33  G. Jones ‘ “Strike out boldly for the prizes that are available to you”: medical emigration from Ireland 1860–1905’, Medical History, 54 (January 2010), 55–74, 55. 34  Kelly, Irish Women in Medicine, p. 138. 35  Ibid. The figures quoted are for 452 women medical graduates who matriculated between 1891 and 1922 thirty-five years after their graduation (up to 1969). 36  I. Finn, ‘Women in the medical profession in Ireland, 1876–1919’, in B. Whelan (ed.), Women and Paid Work in Ireland, 1500–1930 (Dublin: Four Courts Press, 2000), p. 103. 37  M. Higgs, Tracing Your Medical Ancestors: A Guide for Family Historians (Barnsley: Pen and Sword Books, 2011), p. 23. 38  Spencer, Arrangements for the Integration of Irish Immigrants, p. 40. 39  Kelly, Irish Women in Medicine, p. 143. Kelly has found that Irish based women doctors who graduated after 1918 were more likely to be general practitioners. 40  One of these doctors specified they graduated through the Royal University of Ireland (RUI) system, which transformed into the National University of Ireland awarding body. 41  Kelly, Irish Women in Medicine, p. 145. 42  The applicant (file number 16621) was a 38-year-old doctor born in London although having an Irish father and wife (who was also a doctor and applicant) (file number 16622) who stated that he would volunteer for the Irish Army, and, if not accepted, would complete a National University of Ireland higher degree. A male applicant, a 27-year-old nursing orderly from Laois (file number 19158) also stated joining the Irish Army as his reason for return. 43  B. Walter, Outsiders Inside: Whiteness, Place and Irish Women (New York and London: Routledge, 2001). 44  Redmond, ‘The thermometer and the travel permit’, p. 106. 45  Ibid., p. 107. 46  Spencer, Arrangements for the Integration of Irish Immigrants, p. 40. 47  Working Party on the Recruitment and Training of Nurses Minority Report  (1948), pp. 3–4. 48  Abel Smith, History of the Nursing Profession, p. 215. 49  G. Jones, ‘ “A mysterious discrimination”: Irish medical emigration to the United States in the 1950s’, Social History of Medicine, 25:1 (February 2012), 139–56. 50  NAI, DTs 14249/Annexe. Commission on Emigration and Other Population Problems Majority Report, 1948–54 (1954), p. 134. 51  Spencer, Arrangements for the Integration of Irish Immigrants, p. 15. Spencer argued that Ireland was also exporting her ‘social’ and ‘moral’ failures, such as husbands deserting their families and unmarried pregnant women; such a juxtaposition – that Ireland was simultaneously losing the ‘best and brightest’ and the ‘worst’ is a common trope in commentaries on emigration in the post-independence era.

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Index

Aberdeen, Lady 20–1, 131, 134, 156–7 see also Women’s National Health Association amputation 1 Andrews, John Miller 174, 183 Barrie, Hugh 83 Belfast beer shortages and 50 Blitz and 172, 180, 181 evacuation and 184 hospitals and 139–52, 171–85 infant mortality and 24 influenza and 32 nursing and 7, 131 see also Carnworth inquiry; hospitals Belfast Newsletter 35 Bianchi, Leonardo 110 Bigger, Edward Coey 17 Board of Guardians Belfast 33, 38, 148 Downpatrick 39 Newtownards 39 Tipperary 99–100 Boer War 16, 142 British Medical Association 176–7, 197, 198 British Medical Journal 74, 83, 84, 88, 104, 192 Brooke, Basil 183 Browne, Noel 53

Bureau of Military History 94–5, 100–1 Calmette, Albert 70 Carnworth inquiry 175 Carson, Edward 150 Cathcart, Charles Walker 159 Catholicism 117–18 Church of Ireland Gazette 19, 212 Churchill, Winston 45, 46, 49 cod liver oil 68–9 Collis, Robert 66 Commission on Emigration and Other Population Problems 208, 216 Connolly, James 96, 97, 134 Cork 54, 194, 100, 200 influenza and 32, 33 County Board of Health 196 County Down Spectator 35 Craig, Charles 83 Cumann na mBan 95 Daniels, Marc 63 Dawson Report 177–8 de Valera, Eamon 45, 49 Deeney, James 72, 73 degeneration 2–3, 15, 17 Department of Agriculture and Technical Instruction, 21, 156, 159 Department of Local Government and Public Health 51, 54, 67–8

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Index Derry Journal 34 Dillon, John 67–8, 72, 86 diptheria 52 Down County Mental Hospital 6, 109–19 Dublin 52, 54, 55, 56–7, 62, 98, 99, 194, 199, 203 Dublin Lockout and 4, 84 Easter Rising and 81–90, 95–7 infant mortality and 16, 18, 24, 27 see also Easter Rising; hospitals Easter Rising children and 81–90 Irish revolutionary period and 5, 103, 162 medical care and 6, 81–90, 95–7, 133 ‘Economic War’ 193 Emergency Powers Act (1939) 45, 51 Emergency Powers Orders 56 Flynn, Margaret 85 food supplies 2, 3–4, 45–58 beer and 50 black market and 48, 49, 57 bread and 49, 50, 52, 55, 57, 67–9 cannibalism and 45 eggs and 157 flour and 48, 67–9 meat and 48 milk and 21–2, 52, 55, 56, 57, 63, 68–9 rationing and 48 starvation and 46, 47 tea and 48, 50, 55 Frontier Sentinel 34 Gallipoli 135 Galway 47, 53, 57 gastroenteritis 52 General Medical Council 198 Germany, 35–6, 45, 47, 71 Gonne, Maud 20 see also school meals Guérin, Camille 70 gunshot wounds 81–90 Hanna, Henry 83 Hayes, Maurice 104–5 Health Act (1947) 51

Home Rule crisis 4, 115, 157 hospitals Adelaide Hospital and 89 Base Hospitals and 126, 128 Belfast General Hospital and 142 Belfast Hospital for Diseases of the Skin 181 Belfast Union Infirmary and 148–9, 177 Casualty Clearing Stations and 126, 128, 129–31 Cork Military Hospital and 145 Dublin Castle Hospital and 95–6, 97, 131 Duke of Connaught Hospital, Bray and 131–2 Emergency Hospitals Services (Northern Ireland) and 8, 171–85 First World War and 125–35 influenza and 33, 38–40 infrastructure and 7 International Hotel, Bray and 132–3 Jervis Street Hospital and 96–7 King George V Hospital 98, 126, 132 Mater Infirmorum Hospital 147, 150, 174, 177, 178, 181 military hospitals and 38–40, 149–50 Richmond Hospital and 103–4 Rotunda Hospital and 22 Royal Maternity Hospital and 181 Royal Victoria Hospital and 142, 143, 145, 146, 147–8, 152, 174, 177, 181, 200 St. Ann’s Hill and 134 St. Ultan’s and 68–9 sweepstakes and 72 , 174 Temple Street Hospital and 81–90 tuberculosis and 62 Ulster Hospital for Children and Women and 181 Ulster Volunteer Force Hospital 147, 149–51, 152 workhouse hospitals and 38–40, 148–9, 173, 177 see also National Health Service; nursing; tuberculosis: sanatorium and hunger strikers 1, 5, 99

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Index infant mortality (and welfare) 3, 15–27, 51–2 statistics and 23–6 Infectious Disease (Notification) Act 38 influenza 1, 3, 23, 25, 26, 31–41 hospitals and 33, 38–40 Local Government Board and 37–40, 41 media coverage and 34–7 spread of and 32–4 Irish Army Medical Service 198–9 Irish Citizen 19–20, 21 Irish Civil War Irish revolutionary period and 5, 6 medical treatment and 100, 103–5 mental health and 6, 109–19 Irish Free State Medical Union 198, 199 Irish Homestead 18, 21 Irish Independent 34, 37 Irish Journal of Medical Science 192 Irish Medical Students Association 198 Irish News 34 Irish Nursing and Hospital World 213 Irish Parliamentary Party 5, 40 Irish Republican Army/Brotherhood 5, 94, 95, 100, 101–5, 110, 116–17 Irish Times 18, 36 Irish Volunteers 4, 101, 114–15, 156 Irish War of Independence Irish revolutionary period and 5, 6 medical treatment and 97–103 Jessop, W. J. E. 68–9 Kraeplin, Emil 110 Krafft-Ebing, Richard von 114–15 Lady of the House 19 Laverty, Maura 66 Lynn, Kathleen, 34–5 MacNeice, Louis 45 McQuaid, John Charles 52, 72 McSweeny, Christopher J. 62 McWeeney, E. J. T. 73 Manchester Guardian 47

maternal mortality 3, 15–27, 51–2 medical employment 2 medical ethics 1, 2 Medical Press and Circular 210, 212 mental health 1, 6, 109–19, 127, 129, 177, 180 dementia and 110 hallucinations and 109–19 Irish Civil War and 109–19 see also Down County Mental Asylum; shell shock Mental Health Treatment Act (1945) 51 midwifery 22–3, 25, 26, 51 Midwives (Ireland) Act (1918) 22–3, 26 migration 2, 8, 191–203, 206–16 Millin, Samuel Shannon 15 Munich Crisis 47 Myles, Thomas 102–3 National Army Medical Corps 103–5 National Baby Week 18, 21, 26 National Health Insurance Acts 51 National Health Service 8, 171–85, 207, 215 national insurance 174 New Ireland 20, 21 New York Times 36 Newry 115–16 Newsholme, Arthur 17, 37 Nolan, Michael 6, 109–19 Northern Ireland 1, 5, 8, 51, 116–17, 171–85, 200–1, 202–3 see also Belfast; Troubles, the Northern Whig 35 Notification of Births (Ireland) Act (1915) 22 nursing 7, 38, 39, 41, 139–52, 206–16 see also Queen Alexandra’s Imperial Military Nursing Service Reserve; Territorial Force Nursing Service nutrition (and diet) 1, 2, 3–4, 16, 45–58 tuberculosis and 52, 67–9, 74 vitamin C and 55 vitamin D and 48, 67–9, 73 see also food supplies

Index Ó Brion, León 53–4 Ó Cadhain, Mártin 66

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Plunkett, Joseph 96–7 Pollock, Hugh MacDowell 174 Portadown Express 36 Pravda 47 Price, Dorothy 68–9, 70, 71–3 prosthetic surgery 127 Queen Alexandra’s Imperial Military Nursing Service Reserve 143, 144, 145, 146, 201 Red Cross 71–3, 85–6, 95, 128, 129, 150, 155, 156 Republicanism (or nationalism) 3, 4, 5, 6–7, 19–21, 22, 35–7, 40, 97–8, 172 see also Cumann na mBan; Easter Rising; Gonne, Maud; Irish Republican Army/Brotherhood; Irish Volunteers; Sinn Féin; United Irishwomen rickets 54–5, 68–9, 74 Rigby, Hugh 197–8 Rowlette, Robert 72 Royal Army Medical Corps 94–105, 148 Easter Rising and 94, 95–7 Irish Civil War and 94, 103–5, 115 Irish enlistment and 5, 6, 8, 191–203 Irish Republican Army and 94 Irish War of Independence and 94, 102 medical treatment and 7, 85, 130 returning members of the 99–103 Royal College of Physicians in Ireland 18, 101, 214 Royal College of Science for Ireland 157–66 Royal College of Surgeons of Ireland 18, 68, 101, 110, 214 Ryan, James 46 St. John’s Ambulance Brigade 128, 156, 157 school meals, 20 see also Gonne, Maud

Scotsman 36 shell shock 1 Sinn Féin 5, 34–5, 40, 95 see also Lynn, Kathleen smallpox 50 soap 48, 53 Spender, W. B. 182 Sphagnum moss 7, 155–66 Stocks, Percy 61, 63 suffragettes 4, 19–20 surgery 82, 87–8 Territorial Force Nursing Service 144 tetanus 84 Times, The 36 Troubles, the 1 tuberculosis 1, 2, 4, 16, 52–3, 61–74, 211 BCG vaccination and 4, 70–1, 73 causes and 61–2, 67–9 children and 66–7 diagnosis and 69–71 epidemiology and 61–3, 64–7, 73–4 Europe and 64–7, 70–1, 74 flour extraction and 54–5, 67–9 National Association for the Prevention of Tuberculosis 71 sanatorium and 63, 70, 74 tuberculin testing and 56, 61, 70–3 Tuberculosis Act (1945) and 51 Women’s National Health Association and 71 see also Price, Dorothy typhus 53–4, 63 Ulster Medical Journal 192 Ulster Special Constabulary 109, 116 Ulster Volunteers 4, 115–16, 144, 149–50, 150–1, 156, 157 Unionism 3, 4, 19–21, 35–7, 40, 116, 144, 149–50, 165, 174, 183 see also Ulster Volunteers United Irishwomen 21–2, 156 venereal disease 34–5, 53 Voluntary Aid Detachments 130, 135, 150, 155–66

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Wallgren, Avrid 70–1 Ward, Con 67–8 Warren Fisher Committee 193 Webb, Ella 162

Women’s National Health Association 16, 19, 20, 21, 22, 71, 156 Working Party on the Recruitment and Training of Nurses 216