|Meath Hospital, Dublin|
Narratives of venerable teaching hospitals are usually upbeat and positive, delineating progress and advances made in the face of adversity and hardship. This is also the case for Meath Hospital, the most celebrated of the wave of voluntary hospitals founded in Dublin in the eighteenth century.1 Established in 1753 as a charitable institution to serve the poor of Dublin, the hospital struggled in its early years until a large grant from a benefactor, Thomas Pleasants, rescued it and enabled a move to a new building in 1822. The new site had fascinating echoes of literary Dublin, formerly the paddock where Dean Jonathan Swift kept his horse. The list of achievements of the Meath Hospital is impressive, particularly during what has been termed its golden age (1826-43) arising from the remarkable partnership of two celebrated physicians, Robert Graves (1796-1853) and William Stokes (1804-1878).2 Dynamic, innovative and mutually supportive, they introduced bedside teaching to the English-speaking world, produced several key textbooks, described the eponymous syndromes of Graves disease and Stokes-Adams attacks, and oversaw radical changes in treatment. For example, up to that point, a key element of treatment of fever had been to starve the patient. Graves, well ahead of the development of modern theories of clinical nutrition, took the opposite approach with positive results. He was sufficiently proud of this that he proposed that his epitaph should be ‘he fed fevers.’ The impact of the work of the Meath Hospital during this period was significant, with students and physicians travelling from many countries, and in particular from North America, to visit and study at the Meath Hospital. The resulting diffusion of practice was wide-reaching. Sir William Osler gave some indication of this in his oration at the bicentenary of medical school of Trinity College Dublin in 1912. “I owe my start in profession to James Bovell, kinsman and devoted pupil of Graves,” he said, “while my teacher in Montreal, Howard Palmer, lived, moved, and had his being in his old masters, Stokes and Graves”. This sentiment finds an echo in the admiration expressed by the great French physician, Armand Trousseau, of the contribution of Graves to medicine. He wrote: “Graves, is, in my acceptation of the term, a perfect clinical teacher. An attentive observer, a profound philosopher, an ingenious artist, and an able therapeutist: he commends to our admiration the art whose domain he enlarges, and the practice of which he renders more useful and more fertile.” The inventiveness and drive for progress was not limited to Stokes and Graves. One of their colleagues, the surgeon Frances Rynd (1801-1861), is credited with the invention of the hypodermic syringe. Although the intensity of innovation was not sustained after the departure of Graves and Stokes, the hospital remained central to clinical and academic medicine in Dublin. In the twentieth century it was the first hospital in Ireland to provided dedicated services in liaison psychiatry (with the title of ‘Alienist’) (1933), urology (1951) and acute stroke (1995). From a research perspective, key research on successful treatment of Helicobacter Pylorii originated from the Meath Hospital in the 1980’s.3 The hospital amalgamated with two other voluntary hospitals and in 1998 moved to a new site in the suburbs of Dublin as the Adelaide and Meath Hospital Dublin, incorporating the National Children’s Hospital: it continues as one of the two main teaching hospitals of Trinity College Dublin. Funds raised by the sale of the Meath Hospital building support the Meath Foundation, which supports research and the arts in the new hospital. Yet there is a darker aspect to the history of the Meath Hospital, one more clearly delineated by historians who are not physicians.4 Nepotism, sectarianism and divisive politics were part of their very fabric, and yet these facets of its tradition rarely find expression in our professional discourse. Reflecting a broader sectarian and class divide, medical staffing in such charitable hospitals in Ireland was largely confined to those of the Protestant faith in a country where the vast majority of the population were Roman Catholic. In the Meath Hospital, this bias was further exacerbated by an arrangement in 1773 between the medical board and the hospital whereby the medical board could appoint their own successors, in return for not accepting an annual Treasury Grant of £100. This not surprisingly led to frank nepotism, and a remarkable persistence of some surnames (such as Stokes and Smyly) in the large gilt and wood panels detailing physician appointments in the hallway of the hospital. A particularly egregious appointment in 1861 held vacant a surgical post for the under-qualified son of one of the surgeons, Josiah Smyly: this raised bitter discourse in newspapers and the House of Commons in London. Although not remunerated, other than by fees from medical students, the reputational advantage of a position in a teaching hospital was enormous in terms of attracting private practice: for example, Smyly’s son Philip went on to develop a highly lucrative private practice. This system of sectarian nepotism continued through the establishment of the Irish Free State in 1922, and despite the increasing support to the hospital from public funds, until 1949. At this point, frustration led the Knights of Columbanus, a Catholic organization, to prompt exploitation of a loophole in the governance of the hospital permitting any member of the public to become a life-Governor (director) of the hospital for a modest fee. The new hospital board, packed with Catholic representatives for the first time, set up a new panel for the appointment of the assistant physician and surgeon posts, heretofore the usual pathway for the favored candidates of the medical board for permanent posts. Medical and legal chaos ensued, with assistant physicians and surgeons from both regimes in a fractious co-existence: at least one tragic death was linked to the disharmony between the opposing factions. The Irish government finally stepped in and legislated for a secular governance board, with more standard and transparent procedures for appointment of medical staff. Exploring these twin aspects of the history of the Meath Hospital is valuable in many ways. In the first instance it highlights the development of medical history from an iatrocentric, positivist and narrow study of the achievements of medicine towards one which more closely benefits from the techniques and perspectives of historiography, the methodology of vocational historians.5 In so doing, without denying the remarkable achievements of major innovators in clinical medicine and research, we are able to see a fuller picture of how doctors perceive themselves, and often are unaware of how they fail to recognize the intertwining of their own economic and personal interests with protestations of professional autonomy.6 In this context, the most recent history of the Meath Hospital2 shows an admirable blend of scrutiny of newly discovered primary sources and due attention to the moral agnosia of the physicians to the intrusion of sectarianism, nepotism and personal gain of their actions. Reading the contemporary defense by the Meath Hospital physicians of practices that we would now recognize as unacceptable is salutary, we should avoid self-congratulation and reflect as to how we may still fail to give due recognition to our own conflicts of interest in our defense of professional autonomy, as well as prejudices based on faith, race or age. Learning from the complex and multi-layered history of our great hospitals, such as the Meath Hospital, can assist us in formulating a better future for the profession and health systems. Such narratives reinforce Santayana’s aphorism that progress, far from depending on change, depends on retentiveness.
- Coakley D. The Irish School of Medicine: Outstanding Practitioners of the 19th Century. Dublin: Town House; 1988.
- Gatenby P. Dublin’s Meath Hospital, 1753-1996. Dublin: Town House; 1996.
- Humphreys H, Bourke S, Dooley C, et al. Effect of treatment on Campylobacter pylori in peptic disease: a randomised prospective trial. Gut 1988;29:279-83.
- Geary LM. Medicine and charity in Ireland, 1718-1851. Dublin: University College Dublin Press; 2004.
- Burnham JC. A brief history of medical practitioners and professional historians as writers of medical history. Health and History 1999;1:250-273.
- Culbertson RA, Lee PR. Medicare and physician autonomy. Health Care Financ Rev 1996;18:115-30.