There was little about the youth of Sarah (commonly referred to as Sal) O’Malley (née Joyce) to suggest that she would reach the top of the medical profession, nor was there much fortune evident in the timing or location of her upbringing. Born to a sheep rearing family in remote Connemara in the west of Ireland, she attended school in Kiltimagh, Co Mayo. This village, if it is known for anything, it is as the likely etymological root of the word “culchie”- an Irish slang term tantamount to a “country bumpkin”. Nonetheless, her family held a progressive attitude towards education. Notably, they taught their children at home, at times employing a private tutor to supplement school lessons. From this background she entered medical school at University College Galway (UCG) in 1916, graduating as MB, BCh, BAO in 1923. This was somewhat unusual for a woman during this era. Indeed, according to her daughter’s record of events “nine girls registered for medicine, four of them qualified”. There were apparently approximately 100 medical students enrolled in UCG at the time1.

Her undergraduate career needs to be put into a historical context, however, because while medical education is typically considered demanding in itself, these were years of unprecedented change, division and turmoil in Ireland as well as globally. She entered University in 1916, the year of the Easter Rising, and the chaotic armed insurrection that much later culminated in the establishment of the Irish Republic, while in Europe the Battle of the Somme was underway. During her undergraduate years the Irish War of Independence took place, a bloody guerrilla war, which typically divided communities, parishes and even families. She was required to take a year out of university to nurse her own family members, most of whom contracted influenza in the great pandemic of 1919. In fact, her brother, Patrick, died of the disease in March of that year, while her father also died a little while earlier. By the time she was completing university, the country was engaged in Civil War. Ireland at that time was a poor country, and in hospitals patients often slept on floors due to very high levels of bed occupancy, and demand. The hospitals themselves were largely former workhouses. Perhaps then her strength was already evident by the time she started her professional career.

She was now a citizen of the newly formed Irish Free State, which, as its name implies, had a complicated relationship with the United Kingdom, including tariffs and ill-considered trade wars. Nonetheless, having worked for a year as a house surgeon in Galway in 1924, and finding herself interested in anaesthesia, the young Dr Joyce moved to London to gain specialist training in the area. This was necessary since there was no dedicated anaesthesia practitioner in the west of Ireland at that time, and arguably none in the country since general practitioners and surgeons generally provided such care, albeit in a poorly coordinated manner2. Spending several years in London, she studied at a variety of centres, including University College Hospital, Charing Cross, Queen Mary’s and the Chelsea Hospital for Women. Unfortunately, there is very little documentation regarding whom precisely she worked with during this time, but what is clear is that her training there prepared Sarah to apply for a post advertised in 1929 of “Visiting Anaesthetist”, in the Central Hospital Galway.

This innovative and progressive post was advertised as part time, and pensionable, with a salary of £100 annually. Suitable applicants, defined as qualified medical practitioners, would ideally have undergone special training in “the modern methods of anaesthesia”. As sole practitioner for such a large area however, the actual requirements were very onerous. It was mandated that they not only attend the hospital daily at 10.30 am but, also, at such other times as the “medical staff may require”. The letter of offer Sal received is remarkably ungracious and lacking in tones of congratulation – dated October 4th 1929, it reads that “I am directed to state that as no suitable applicant with a competent knowledge of Irish was forthcoming” she was, by government order, appointed to the position1. Ideologically-driven endeavours to re-establish and support the Irish language were intense at this time, with rather limited success. Sal had already worked for a brief time on the Irish-Speaking Aran Islands so she evidently had a good working knowledge of the language, although was not an authentic “Gaeilgeoir” (native speaker).

By now thirty-three years old, she was Dr Sarah Joyce O’Malley, known affectionately as Sally or Sal, having married Conor O’Malley, an ophthalmic surgeon and Professor of Ophthalmology in Galway, approximately five years earlier. He, too, was a remarkable man in many respects, and had served in the Royal Navy Medical Corps 1, 3. He was instrumental in establishing the Order of Malta Ambulance service in Connaught4 for which he was later made a Knight of Malta in recognition of his work with the order. He was appointed Professor of Ophthalmology at the Regional Hospital Galway (later known as University College Hospital Galway) after studying cataract surgery with the renowned Dr Mathra Das Pahwa in India after the World War I.

Sal and Conor worked together extensively, as she was the only trained anaesthesia provider in the locality for many years, and they had a family of five children. In 1932, she was one of the first to join the United Kingdom Association of Anaesthetists founded by Dr HW Featherstone and was invited to take the role of Irish lead for the specialty. This, she declined due to the challenging logistics of travel at the time and her significant family commitments1.

Professional respect and success were clearly evident. However, and presumably unknown to most of her colleagues, Sal had been forced to engage in a protracted dispute with the County Manager in order to receive reasonable remuneration. Having been initially employed on a stipend of £100 annually, she wrote to them in 1945 to emphasise that her salary hadn’t changed in the intervening sixteen years. Clearly this period, encompassing World War Two, was a time of major economic turmoil, with inflation of over 5% in Ireland during 1940 alone for example5. In her correspondence she, quite rationally, correlates her salary to that of her surgical colleagues, which had apparently increased significantly in the relevant period, and also offers an overview of her clinical work in defence of her argument. She notes that her holiday locums are at times paid more than £6 per week – over three times as much as she received. In a lengthy correspondence, she also clarifies the changes she has implemented establishing “Safety First Principles” and by providing structured tutorials to House Surgeons in an effort to reduce operative risks, with the latter changing post every three months. Finally, by the middle of the 1950’s, her remuneration was set at just over £800, perhaps giving a proportionate acknowledgement to the exceptional service she pioneered and delivered.

Dr Joyce-O’Malley was obliged to maintain this correspondence about payment for over 13 years, and at times it offers an insight into her clinical performance. Writing in 1945, she records that she takes “pride in the fact that during my sixteen years dealing with very many thousands of anaesthetics I did not have a single fatality”, while observing that two deaths arose during those years when anaesthesia was administered by House Surgeons. In another letter she cites a record of having provided care during more than 4,500 tonsillectomy cases without a single mortality. One can compare this to the outcomes contemporaneously described by Beecher of about one fatality per 1,500 anaesthetics6; her claim is thus credible while also impressive. Given her professional isolation, the basic technology of the era, the drugs in use, and the limited monitoring available, her clinical performance appears to have been of a superlative standard. Of Sal’s professional reputation, her daughter wrote that “her coolness in a crisis was remarkable and it was on such occasions that her true expertise so frequently averted a tragedy”.

Sadly, most of the evidence relating to the contributions Sal made to teaching and training is only documented in these letters to the County Manager while the rest is anecdotal. It is widely accepted that both she and her husband were popular and leading medical practitioners and educators, rated highly by patients and colleagues. She undertook what we call nowadays a clinical audit, however, there are no formal publications of her work or research, which was largely clinical and reflective of the era. While still in service of the hospital Dr Joyce O’Malley died quite suddenly at the relatively young age of 62. The cause of her death remains unclear.

There are three major ways in which Dr Joyce O’Malley’s legacy is evident today. In the 1940’s in Ireland, the gender pay gap was over 40% and it appears that all of her surgical colleagues were male1, 7. Her personal campaign probably helped to address such inequitable arrangements. Secondly, her courage in undertaking advanced training in England in the immediate aftermath of the War of Independence, and of consolidating links to the United Kingdom Association of Anaesthetists thereafter, was quite likely the start of the warm professional relationship that remains today between Ireland and the UK, across borders that once again seem contentious. And finally, of course, there are many people alive and well as a result of her excellent care, whether they themselves or their parents were cared for by her. Several of her children and grandchildren also trained in medicine and surgery, some of whom are still in practice. The National University of Ireland, Galway (NUIG) annually awards The O’Malley Gold Medal to an outstanding undergraduate, an award named in recognition of the career of both Sarah and Connor O’Malley.

REFERENCES

1. O’Malley Kelly A. Sal O’Malley: pioneering Anaesthetist – A Memoire. Journal of the Galway Archaeological and Historical Society 2017; 67
2. O’Donnell B. Irish surgeons and surgery in the twentieth century. 1st Edition Edn.: Gill Books, 2008
3. O’Gorman R. Galway’s new anaesthetist: ‘Stuffed with learning’. 2017. Available from https://www.advertiser.ie/galway/article/89638/galways-new-anaesthetist-stuffed-with-learning (accessed October 2019 2019)
4. A History of the Order in Ireland. 2018. Available from https://orderofmaltaireland.org/about-us/history/ (accessed December 2019 2019)
5. Bermingham C, Coates D, Larkin J, O’Brien D, O’Reilly G. Explaining Irish inflation during the financial crisis. Central Bank of Ireland Technical Paper 2012; 9
6. Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599,548 anesthesias in ten institutions 1948-1952, inclusive. Annals of surgery 1954; 140: 2
7. Central Statistics Office. Historical Earnings 1938-2015. Earnings by Gender. 2019. (accessed October 2019 2019)

Kim O’Brien^*1, Brian O’Brien^1
1Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
*kim.obrien@umail.ucc.ie