The Tuberculosis Epidemic in Ireland:II

What then accounted for the rising mortality from tuberculosis in Ireland in the late-nineteenth century and what light does her experience throw upon the current controversie s surrounding tuberculosis epidemics? Ireland’s epidemic followed a roughly similar trajectory to that experienced elsewhere in the British Isles. It rose over several decades, peaked and then entered a period of decline. John Brownlee, in his study of tuberculosis for the Medical Research Council, published in 1917, noted that ‘the mortality curve for the whole of Ireland in recent years resembles closely the mortality curve for Scotland as a whole during the period 1860-80. It would thus appear that the epidemic in Ireland may be compared with the epidemic in Scotland in its progress except that the maximum point in the former is twenty years later than the latter.’1 The rise in mortality from tuberculosis in Ireland occurred first in the industrialising regions of the north east. In the 1860s, 1870s and 1880s, Belfast and its hinterland had a higher tuberculosis death rate than any other region of Ireland. 2 Some of the highest rates of mortality in the north east in the 1880s were recorded in the smaller linen towns of Ulster. 3 The incidence of tuberculosis was rising everywhere in Ireland in the late-nineteenth century but the industrial north east suffered first. In Ireland as a whole, tuberculosis peaked at the point when other urban areas, particularly Dublin, caught up with and surpassed the tuberculosis death rate in Belfast. This took place in the 1890s when the rates of mortality from tuberculosis in Dublin finally exceeded those of Belfast. By then mortality rates had also risen in other Irish towns such as Limerick, Cork and Galway. Phthisis was most severe in urban areas, a position which remained unchanged into the twentieth century . Grimshaw’s calculations were that the rate of phthisis in civic unions in 1881 was 280 and in rural 160. 4 From 1891-1900, it was 290 and 175 respectively. 5 By the 1920s and 30s figures calculated for rural areas of the twenty-six counties of Saorstat Eireann by Counihan and Dillon demonstrated that the rural mortality rate from tuberculosis rate was still lower than the urban and had fallen largely in line with the urban rate. 6 63

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Though Ireland remained predominantly an agricultural country, her urban population was growing in the late-nineteenth century. 7 Of the two major cities in Ireland, Dublin and Belfast, Belfast grew most dramatically from the mid-nineteenth century and Dublin’ s population started to rise at the end of the century. 8 Between 1901-10 these two cities accounted for twenty-eight percent of deaths from all forms of tuberculosis in Ireland. 9 The population of other towns in Ireland, with the exception of the smaller industrial towns of the north east, remained static or even fell. By the 1900s, however, there was a rise in tuberculosis there too.10 In addition, although there was emigration and a net fall in population in many rural areas, rural rates of mortality from tuberculosis also increased, although they remained lower than those of the towns and cities. Therefore mortality from tuberculosis exploded, as it were, in the areas of industrial and/or urban growth in Ireland but the effects were felt everywhere. Urbanisation increased the incidence of cases, sustained high levels of infection and raised the overall rates of mortality. Grimshaw in the 1880s noted that rural areas near larger towns had higher rates of tuberculosis mortality than those which were more remote. He believed that tuberculosis spread out from the urban to the rural areas. This certainly happened, but it is important to note other channels of infection in the countryside. Tuberculosis was endemic in Ireland even before the rise in mortality from the disease in the second half of the nineteenth century, and it is possible that rural rates of tuberculosis increased because of changes in social and economic structure or in patterns of migration exclusive to agricultural regions and regardless of urban growth. For example, Irish emigrants from predominantly agricultural areas sometimes passed straight into British and American cities, developed full blown tuberculosis and returned to their home in Ireland aggravating the problem of tuberculosis there. The incidence of rural tuberculosis was, therefore, not just a consequence of a rise in infection in the towns which was then exported to the countryside. Within rural communities there were differences in the rates of tuberculosis mortality arising from conditions specific to these areas. Cronje has pointed to certain exceptional concentrations of tuberculosis mortality in rural parts of England and Wales in the nineteenth century. 11 William Johnston notes that in Japan, although rural rates were lower than urban, ‘Yet a number of rural prefectures had a higher consumption mortality than the national average, higher even than some urban 64

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II prefectures.’ 12 In 1930 a study by R. C. Geary also drew attention to variations in deaths from tuberculosis between rural counties in Ireland and argued that TB mortality was higher in agricultural regions where there was a predominance of small farmers and wage labourers.13 Thus rural tuberculosis rates, whilst undoubtedly affected by the rise in urban rates, were not a simple reflection of them. Other factors from patterns of migration to the character of local industry and farming played a part independent of the urban epidemic. 14 Nonetheless the epidemic in late-nineteenth century Ireland was sustained by high urban rates. The relationship between tuberculosis and urbanisation is however, complex. All the public and private spaces of cities – the factory, the tram, the barber’s shop, the public house, the music hall, the prison, the student dormitory , the boarding house, the police barracks, the shop, the theatre, the school and the home – are rendered places of possible infection. However three things affect this: infection generally depends upon close proximity with a sufferer for an appreciable length of time: some environments are rendered more than averagely dangerous by the conditions in them, and susceptibility to infection differs between individuals as does the chances of that individual developing the full blown disease after the initial infection. Each victim presents an incidence of infection unique to them, not always comparable with others or illustrative of a general rule. Therefore, whilst the tuberculosis epidemic was linked to the growth of the urban environment, this in itself raises questions because urban environments are varied and present a wide range of possible precipitating causes of tuberculosis infection. It is possible, nonetheless, by comparing Belfast and Dublin, to see patterns emerging in the character of the epidemic in Ireland particular to the economic and social structure of the two cities. A variety of individual causes are always at work in the spread of tuberculosis but there may be some particular, underlying environments which give rise to high tuberculosis mortality.

Belfast grew because of industrial development in the nineteenth century. It was the fastest growing urban area in Ireland. In 1821 around 2 percent of the population of the province of Ulster lived in Belfast compared to around 25 percent in 1911. 15 From being a cotton town, though to a more modest extent than the towns of north west England, Belfast changed to linen manufacture in the 1840s. Some cotton manufacturing continued but by the last third 65

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones of the nineteenth century it was a small sector of the economy compared to linen textiles. 16 In 1850 there were 69 linen mills in the north east of Ireland, in 1874 149 and in 1890 162. There was particularly rapid growth from 1854-74, the numbers in linen manufacture rising from 1,121 to 60,316. The growth slowed after 1874 but the linen industry peaked in the years before the First World War. In 1910 there were 75,000 linen operatives in Belfast alone of which five sixths were women. 17 Outside Belfast smaller towns like Armagh. Lurgan and Lisburn were also centres of linen manufacture. Linen was predominantly an industry of young women and girls. The age at which females were allowed to enter the mill full time was initially twelve and later rose to fourteen. In 1871 ten percent of linen operatives were under 15 and fifty percent aged 15-25. 18 In the 1860s, the shipbuilding and engineering industries began to take off in Belfast providing largely male employment. These industries grew particularly fast in the years immediately leading up to the First World War. By 1914 Belfast and its environs was the most important centre of linen manufacture in the world and Belfast a leading centre in the British Isles of shipbuilding and engineering. In contrast Dublin ’s nineteenth century urban development resembled London’s. Dublin experienced a decline in some industrial sectors in the nineteenth century and her importance came from being a centre of government, fashion and the professions. With some important exceptions, the industries she had tended to be those servicing the population or connected to transpor t and import/export. The structure of her industrial and working-class population was, therefore, different in many respects from that of Belfast, with a higher proportion of casual and unskilled labour and of small scale and artisanate manufacturing. The other difference was that, although Dublin provided employment for women, Belfast had a higher percentage of women in industrial occupations. 19 Mary Daly has calculated the percentage of employed women in 1911 in industrial occupations for Belfast and Londonderry (a centre of shirt manufacture) as respectively 73 percent and 59 percent, whilst that for Dublin and Cork was 32 and 29 percent. 20 Social conditions also differed. The poor among Dublin ’s working-class were frequently housed in tenements whose overcrowded and unhygienic conditions were the subject of criticism throughout the late-nineteenth century. In contrast the Royal Commission on the Housing of the Working-Class in 1885 commented 66

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II favourably upon Belfast’ s working-class housing. 21 Similarly, family income was higher in Belfast due to the availability of women ’s industrial work and to the existence of skilled male occupations in shipbuilding and engineering. 22 In Dublin, however, Daly argues that the percentage of unskilled and casual labour increased in fin-de-siècle Dublin putting pressure on wages and housing among the poorest of Dublin’s working-class. When phthisis rates in Dublin and Belfast were compared at the turn of the century, the influence of industrial conditions tended to be downplayed. Dublin had few industries yet, by 1900, Dublin’s tuberculosis mortality rates had overtaken industrial Belfast. The debate about the relationship between tuberculosis and poverty was also influenced by differences between the two cities. Belfast, although it had a stratum of casual and poorly paid unskilled labour, was prosperous. It was described in 1908 as ‘a town of good wages in which the labouring-class live probably better than in any other part of Ireland’ . 23 Yet Belfast’ s tuberculosis mortality was greater than Dublin’s in the 1880s, and in 1908 it still had a serious problem with the disease. In fact wages among women linen workers were amongst the lowest in the textile industries of the United Kingdom, although they rose in real terms between 1883-1905. Wage rates for unskilled labourers in Belfast were also low compared to those in Britain. In contrast skilled occupations in shipbuilding and engineering were highly paid and roughly comparable to other regions of the United Kingdom. 24 Nonetheless, the availability of work and the existence of combined family incomes meant that Belfast qualified as one of the more prosperous parts of Ireland for the nineteenth century working-class. Another significant fact about the Irish tuberculosis epidemic was that throughout the nineteenth century women in Ireland had a higher mortality from tuberculosis than men. 25 This situation lasted up until the 1930s when male and female rates converged in both parts of Ireland with the male rate overtaking the female. 26 This contrasts with England and Wales where Gillian Cronje has observed that in 1851 more women than men died of tuberculosis but by the end of the decade, ‘the proportion of deaths from tuberculosis was falling faster for both sexes in every decade; but it was falling faster for women’. 27 This meant that by the end of the nineteenth century a pattern was established in England and Wales of lower tuberculosis mortality for women. 28 This fall in female mortality from TB was closely associated with the process of urbanisation. In rural England and Wales, with some 67

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones significant exceptions, the death rate for tuberculosis remained higher for women than men, but as urbanisation increased so the male rate rose above the female. 29 The predominantly rural nature of Ireland, therefore, must have contributed to the difference in male and female mortality from tuberculosis in Ireland and, indeed, the phenomenon of higher female mortality from tuberculosis in rural areas of Ireland continued into the twentieth century even when male and female mortality rates for tuberculosis were converging overall. 30 Child bearing can also aggravate the problem of tuberculosis in women and is implicated in stillbirths and in perinatal deaths of children.31 This however does not appear to have been a more severe problem in Ireland than in England and Wales. The Belfast Health Commission in 1908 reported for the period 1891-1900, the rate of deaths for infants under 1 year in Belfast attributable to tuberculosis as 4.6 per 1000 live births compared to figures of 7.9 for England and Wales and 8.2. for Manchester for the same period. 32 The Registrar General for Ireland’ s 1901-10 Decennial Summary recorded a rate of infant death under 1 year attributable to tuberculosis of 4.03 per 1000 live births for the whole of Ireland for the decade. 33 However, we do not know enough about the history of infant and maternal mortality in Ireland to be sure how well founded the comparisons are. 34 There were differences in registration practice and, whilst in England and Wales it became compulsory to register stillbirths from 1927, this was not the case in Northern Ireland until 1961 and 1994 in the Republic of Ireland. In reality from 1948 in Northern Ireland and from 1957 in the Republic it became routine practice to collect stillbirth figures and include them in the figures for infant mortality but, between 1927 and these dates, the effect of tuberculosis in infant death must have been underestimated. 35 Maternal mortality was higher in Ireland than England and Wales throughout most of the late-nineteenth and twentieth century and the proportion attributed to causes other than puerperal sepsis- among which tuberculosis would be included – was also higher. 36 The excess in maternal deaths in Ireland attributed to ‘other causes’ was greater in the period which coincided with the peak of tuberculosis mortality in Ireland but whether the two factors were connected is a matter of debate. 37 A survey by the Registrar General of 6,526 deaths in childbirth for the period 1901-10 found that only 125 could be attributed to tuberculosis of which 117 were due to pulmonary TB or phthisis. 38 Thus TB accounted for only a fraction – 2 percent – of deaths in childbirth and an even smaller proportion of the total of 45,407 deaths of women from tuberculosis from 1901–10. However, 68

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II maternity may have had a more long term indirect effects not necessarily perceptible at the time. The complications of frequent pregnancy must have depressed the health of a number of women making them liable to infection or, alternatively, to a recurrence of a tuberculous infection. There were other factors which had a more direct influence upon high female rates for tuberculosis in Ireland. A major contribution was made by the nature of industrial development in Ireland. Female mortality for tuberculosis was lower than the male in Leinster, the most urbanised province of Ireland, but in Ulster the female rate was higher than the male even though it was the fastest growing urban and industrial area in the nineteenth century. Three of its nine counties were predominantly rural but the province was, by 1871, second only to Leinster in the degree of urbanisation. 39 In the nineteenth century no official statistics were computed showing male and female differential in mortality from tuberculosis for individual towns and cities. Anecdotal evidence and the findings of various health inquiries in the period suggest, however, that in Belfast and the surrounding industrial areas, tuberculosis mortality among women was not falling relative to the male as urbanisation advanced but was, for much of the nineteenth and early-twentieth century, higher than the male. In 1872 C. D.Purdon, certifying surgeon for Belfast, assessed the physical condition of Belfast’s mill operatives at the request of the Chief Inspector of Factories. 40 He divided Belfast’s population into gentry, mercantile and professional (7,000), labouring and artisan (165,229) and flax workers and linen mill operatives (28,127). He concluded ‘that the flax manufacturing-classes suffer far more from phthisis than the other two classes, nearly three fifths of those that die annually being taken off by diseases of the Respiratory Organs’. 41 Purdon re-examined the situation in 1874. Between 1864 and 1873 he considered that, among linen mill operatives, ‘the average death rate from phthisis has increased, notwithstanding the great improvement that has taken place in the sanitary state of the mills’. 42 Purdon’s raw figures are not necessarily reliable but his opinion about the prevalence of phthisis and its recent increase in the 1860s and 1870s was widely shared among certifying medical officers in linen districts. 43 Respiratory complaints, particularly bronchitis, were widespread among mill workers. It is possible that some bronchitis, emphysema and lung cancer were diagnosed as tuberculosis and vice versa. However, the symptoms of consumption were well known and it was categorised separately from other respiratory diseases in sanitary 69

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones reports on the linen mills. It was also found in unexpected places. Belfast’s certifying surgeons expected to find pulmonary tuberculosis in the dusty parts of linen manufacture because the inhalation of dust was considered to be a cause of consumption. Therefore Purdon was surprised to find that the incidence of pulmonary tuberculosis was higher in the non-dusty sections of the industry, wet and dry spinning, a situation confirmed by subsequent surveys of the health of mill workers. Women workers were concentrated in the wet and dry spinning manufacturing process but Purdon was largely blind to the possible links between industri al conditio ns and female tuberculosis mortality, instead focusing upon the personal habits and domestic environment of the mill workers. By 1890, however, attention began to focus more closely upon the effect of industrial occupations upon women. E. H. Osborn conducted an enquiry, 1891-2, into general mortality among linen textile workers in Belfast in which he found that 53 percent of the female textile workers who died in that period, died from phthisis as opposed to 34.8 percent of male textile workers and 21 percent of male and females in other non-texti le occupations. 44 Osborn believed this to be an underestimate of the toll taken upon women by work in linen because it excluded many classified as housewives who had contracted the disease earlier in their life while working in the mills. The extent of tuberculosis mortality in Belfast emerged as a result of an official enquiry conducted in 1907 on behalf of the Local Government Board of Ireland by H. W. Bailie, Belfast’ s medical superintendent of health. This was published in 1908 as the Report of the Belfast Health Commission . Bailie computed mean annual death rates in Belfast and Manchester for three years 1900, 1901 and 1902. Overall mortality between the two cities was roughly comparable – corrected for age and sex it was 243 per 100,000 living persons for Belfast and 245 for Manchester. What emerged, however, was the large part played in Belfast’s mortality rates by those diseases grouped together as zymotic and by tuberculosis, particularly pulmonary tuberculosis. Zymotic disease accounted for a rate of 305 per 100,000 in Belfast and 290 in Manchester. The mortality for phthisis in Belfast was even higher at 317 to Manchester’s 210. 45 The male and female differential was also striking. Overall, male mortality in Belfast was higher than female, 224 to 218 – in Manchester it was 234 for men and 204 for women – but for phthisis, female rates were substantially higher.

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Deaths from phthisis per 100,000 for Belfast and Manchester for 1900, 1901 and 1902

Belfast Manchester Male Female Male Female 293 338 268 162

Source: Belfast Health Commission 1908. Calculated from Table XIX, 33.

There was an excess of female deaths attributable to phthisis at every age range in Belfast except 20-25 and after age 45, whereas in Manchester after age 15 the female rate dropped and after 20 it was lower than the male for all subsequent decades. The greatest differential in deaths from phthisis between Manchester and Belfast was in the age ranges 15–35, particularly 15–20. After age 35 the rates between the two cities converged. 46 Bailie believed that industrial conditions and the pattern of female employment played a role in the high female death rate from phthisis. He conceded that women in Manchester had a lower mortality rate than men overall and, specifically , a lower rate of mortality from pulmonary tuberculosis, yet Manchester was, like Belfast, a textile town with a higher than average percentage of women working in industrial occupations. Female cotton workers in Lancashire also had, by the turn of the century, a lower general mortality rate than other categories of female workers. 47 Nonetheless, Bailie still believed ‘in view of the large number of women employed in the branches of the linen industry in Belfast, it may be that industrial causes have operated conducive to the exceptional female phthisis mortality at these ages.’48 In 1908, in a memorandum from the public health committee of Belfast Corporation to the chief secretary of state for Ireland, James Bryce, on the subject of the Belfast Health Commission , Bailie backed up this argument by comparing Belfast with another Lancashire textile town, Bolton. In Belfast ‘for every male employed in the textile (linen) industry 33 females are employed’ whereas the corresponding figures for Bolton were ‘for every 13 males employed in the textile (cotton) industry , only 18 females are employed’ . Therefore Bailie argued that ‘ taking textile and non textile occupations together, the ratio was for Belfast 54 males to 54 females; for Bolton 47 males to 22 females. It would therefore seem that the greater the industrialisation of females the higher the rate of tuberculosis amongst them.’49 71

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The idea that industrial conditions contributed to high mortality from tuberculosis was controversial. 50 J. A. Lindsay, professor of medicine at Queen’ s University and formerly the medical superintendent of Whiteabbey Tuberculosis Sanatorium, argued before the Committee on Humidity and Ventilation in Flax and Linen Factories in 1914 that mortality from tuberculosis was due to ‘bad housing, insufficient diet and, to some extent emigration as leaving behind the less fit to carry on’ . Lindsay told the Committee ‘ At Dublin, where there are no factories, it is higher than Belfast… Before you conclude that the factories have a high tubercular rate, you have to remember that the rate in Ireland was everywhere high.’51 Dr John Elder MacIlwaine, visiting physician to Forster Green Hospital for Diseases of the Chest and Consumption, also gave evidence to the Committee and he attributed the prevalence of tuberculosis among wet spinners to social class rather than industrial conditions. He argued that although phthisis ‘seems to occur rather frequently among wet spinners, the wet spinners I think, if one may say so, are probably the poorest operatives and one would naturally expect that there would be more phthisis on account of their home and general conditions’. 52 However, there was consciousness of the contribution made by the linen mill to ill health among mill workers, employers and public health officials in nineteenth century Ulster. Two complaints were considered to be caused by the mill. These were popularly referred to by mill workers themselves as ‘ poucey’ and ‘ mill fever’ . Poucey, contracted in the dusty parts of the linen manufacturing process, led to respirato ry obstruction, coughing, and phlegm and was commonly believed to contribute to the high rate of bronchial complaints especially among men who mostly worked in the dusty areas. ‘Mill fever’ described the fainting, nausea and disorientation which affected new entrants to the mill due to the high temperatures, humidity and noise in the wet and dry spinning sections – the domain of women. 53 Neither led directly to pulmonary tuberculosis, although the certifying surgeons in the mid-nineteenth century expected the dust in mills to precipitate phthisis and modern medical opinion would attribute some, at least, of certain types of tuberculosis to this cause. Mill fever overcame new entrants to the mill and cleared up quickly after a few days. However mill fever illustrates the physiological shock induced by conditions in the mill. The heat and humidity were very high and although efforts were made to reduce both in the late- nineteenth century, they remained a significant problem right up to 72

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II the First World War and beyond. In addition linen mills tended to be larger and more crowded establishments than cotton mills with higher levels of humidity. 54 Pulmonary tuberculosis is infectious and the conditions outlined above did not, in themselves, cause tuberculosis mortality among textile workers but rather created an environment which assisted its spread. Adolescent girls appear, in any case, to be particularly susceptible to the disease and their introduction into the crowded and debilitating conditions of the mill exposed them to the danger of infection.55 Two other facts about the nature of women’s employment in linen should be noted. The peak age for employment for women in Belfast was between the ages 15 to 19 compared with 20–24 in other major Irish cities. Secondly, among recent migrants to Belfast in 1901, in the age range 15– 24, women outnumbered men by almost three to two. This indicated a continuing pull of young females into the factory from the surrounding rural counties. Most of these departed the mill on marriage, although in 1871 around a quarter of women working in the mills were married. 56 Recent migration, youth and debilitating and overcrowded industrial conditions combined to make the female linen operative vulnerable to consumpt ion. The evidence from Manchester contradicts this but the solution to the paradox might lie in the fact that Bailie’s investigation covered 1901–2. By then there had been over a hundred years of industrial development in the Lancashire town and the effect of any short term epidemic rise in tuberculosis would have played itself out. Similarly , the rate of mortality from consumption among women in the industrial north east – in what became, after 1922, Northern Ireland – fell relatively rapidly after the First World War. By the mid-1930s it had fallen below that of men and studies of the pattern of mortality among women textile workers in Northern Ireland in the 1930s showed that their tuberculosis mortality had converged with other categories of female workers. 57 A better comparison would be to look at the decades in which the mill was first established as part of the industrial landscape in each city. The lack of statistical information about tuberculosis mortality for the textile districts of Britain in the early-nineteenth century makes this very difficult. However, there are other possible examples nearer in time to the Irish epidemic. Japan’ s tuberculosis epidemic recalls some features of the one in Ireland. Japan ’s tuberculosis epidemic occurred between 1880 and 1930 with her national mortality rates peaking in 1918–20. William Johnston, the historian of the epidemic, attributes the rise in mortality from consumption in Japan to various 73

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones factors; urbanisation, greater volume of migration within Japan and industrialisation. Among industrial causes he singles out textile workers as particularly vulnerable to the disease. Between 1886 and 1913 the number of textile factories (silk and cotton) rose from 498 to 8,332 and textile workers from 35,200 to 501,000. In 1913 ninety- two percent of employees in silk and eighty-three percent in cotton were women, mostly in their in their teens and twenties. They suffered more noticeably from phthisis than other factory workers and the spinners among them suffered the worst of all. 58 In Johnston’s account conditions for female factory workers were considerably more oppressive than those in European textile factories in the late-nineteenth century. However, there was the same basic problem of the effect of exhausting work in noise, heat and damp on young, often adolescent, girls crowded together many of whom were recent arrivals. The problem in Japan was aggravated by the migratory character of much of the workforce who lived in dormitories attached to the factory and often returned to their native village, particularly if they fell ill. It is this migratory pattern which, Johnston argues, helped spread tuberculosis throughout Japan, particularly into the rural areas, and exacerbated the overall problem. 59 At the height of the tuberculosis epidemic in Ireland the contribution of industrial conditions to the spread of phthisis received little attention except among those medical officials directly concerned with the districts in which the mills were located. The factory inspectorate and some enlightened employers made efforts from the mid-nineteenth century to improve conditions in linen by introducing a mask – the Baker respirator – to prevent inhalation of dust, extracting dust through ventilators and providing splash boards and aprons to reduce soakings. This was done to improve general health rather than specifically reduce mortality from phthisis, but legislation on levels of heat and humidity might very well have contributed to controlling the rate of tuberculosis infection. However the regulations were not rigorously enforced by those charged with local supervision of factory conditions. 60 There was also resistance to them among the workforce. Linen thread required a higher humidity than cotton otherwise it broke more frequently with a loss of earnings to the operative. This point was made by the operatives themselves to the Committee on Ventilation and Humidity in 1914. Of six petitions from operatives to the committee only one asked for measures to reduce the temperatures. The general opinion among linen workers was that ‘by reducing both temperature and humidity we found it greatly increased our work’. 61 Measures specifical ly aimed at controlli ng pulmonary 74

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II tuberculosis were introduced into the factory in the early-twentieth century but these were mostly injunctions to better personal hygiene among the workers – for example to avoid spitting on the floor, to sweep the factory floor more frequently and abandon the practice of ‘kissing the shuttle’ (pulling the thread though the eye of the shuttle by sucking on it) – rather than tackling the fundamental problems of dust, heat and damp. The disproportionate effect upon women of work in the mills was not widely discussed except in one respect. The cultural and social changes brought about by the growth of industrial Belfast, the ‘unnaturalness’ of female factory employment and the unseemly behaviour of the factory female wove itself into the discourse about consumption. Purdon believed the increase in mortality from consumption was caused by the collapse of the old style, rural family structure; ‘the workers not being derived from the same source as formerly when they were reared in the country… but are the offspring of workers whose constitutions have been impaired by drink, improper diet, inferior and insuffici ent house accommodation, unhealthiness of employment and have been too early married, who have been brought up on an improper diet and injured their constitutions by bad habits.’ 62 Much of the advice tendered to mill workers about the avoidance of consumption by certifying surgeons was not medical but moral. It was driven by the desire to recreate the stability of family and domestic arrangements seemingly threatened by industrialisation. 63

Linen textiles patterned the character of the tuberculosis epidemic in the north east but this does not exclude the contribution made by other factors. Men also suffered increasing rates of mortality from consumption in Belfast. The overall mortality of men in Belfast in 1908 was higher than that for women, although rates of death from TB were lower. Poverty and poor housing, as well as industrial conditions, contributed to the problem. Nor can other occupational conditions be excluded from contributing to the tuberculosis problem. In Dublin’s case, dusty trades and overcrowded sweatshops were also the site of infection. Some of the highest incidences of mortality from consumption in late-nineteenth century Dublin were recorded among the skilled male artisan occupations carried on in dusty, enclosed and overcrowded workplaces. Tuberculosis rates in Dublin were converging with those of Belfast in the 1890s and overtook them in the first decade of the twentieth century. 64 Did the pattern observed in other cities of the 75

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United Kingdom of a higher male tuberculosis mortality than female apply to Dublin? The relative mortality from tuberculosis of the sexes in Dublin has to be inferred from indirect evidence but much of this evidence supports the conclusion that it did. It is generally accepted that life expectancy for women in Dublin was higher than that for men in the nineteenth and early-twentieth century. 65 The province of Leinster, the most urbanised in Ireland and in which Dublin city (excluding the suburban areas) accounted for 20.6 percent of the total population in 1891, had a higher death rate for phthisis among men than women throughout the late-nineteenth and twentieth centuries. In 1930 a calculation of Dublin County Borough’s male and female differential for tuberculosis mortality for 1923–8 showed that the male mortality for pulmonary TB was substantially higher in Dublin and three other county boroughs than the female, even though in the rest of the Irish State which, following partition in 1922 comprised twenty-si x counties, female mortality from pulmonary TB was higher. 66 It was unlikely that this considerable differential in Dublin was of recent origin. Evidence from figures for tuberculosis mortality computed by occupation in Dublin suggests that the male rate was higher. The clothing trades included male tailors who, in a survey of occupational mortality for Dublin in the 1860s, were shown to have high death rate from consumption. By the end of the century it was largely women who were employed in this sector. 67 The pulmonary tuberculosis rate for the clothing trades was 270 in 1885, 252 in 1898 and, between 1901-10, 180. Grimshaw’s social classification table for Dublin showed that of the ten occupational categories assigned to class 3 and 4 (lower middle-class and working-class ) the clothing trade was fifth in 1885 and 1898 and fourth in 1901-10 in terms of its phthisis rate. This indicated a continuing problem of high mortality from consumption in this occupational category but not one higher than, for example, hawkers, porters and labourers who, except for hawkers, were almost exclusively male. The latter were a growing occupational group in Dublin comprising two and half times the number in the clothing trades in 1885, three and half in 1898 and four and half times as many in 1901-10. Their phthisis rate in the same years was 394, 341 and 300. Domestic service accounted for 39 percent of women employed in Dublin in 1911 and it was also a predominately female occupation. 68 Its phthisis rate was 157 per 100,000 in 1885, 123 in 1898 and 130 in 1901-10. In 1885 and 1898 domestic servants had the third lowest rate of death from phthisis recorded for any occupational category. In 76

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1901-10 only the occupational categories assigned to the professional and independent class and middle-class had lower phthisis rates and of these the category ‘clerical, legal and medical, naval and military officers and heads of public departments’ had the same rate as domestic servants. Clerks, who were assigned to the middle-class, had a substantially higher rate (230) than domestic servants. 69 It could, of course, be the case that domestic servants, who were often recruited from rural counties adjacent to Dublin, went home if they contracted the disease thus inflating the figures there. Higher rates for pulmonary tuberculosis in rural areas near the cities compared with other more distant rural areas had been noted by Grimshaw in the 1880s. This would mean that the rate of mortality for TB for domestic servants in Dublin was underestimated. But there are other possible reasons for the low incidence, including the fact that domestic servants working in the homes of the middle and upper-classes were among the better paid female workers in Ireland and shared the same general domestic environme nt as their employers.70 The figures for female mortality for Dublin, particular for the clothing trades, suggest that the involvement of women in manufacturing resulted in greater phthisis mortality, that in Cronje’s words, there was a ‘ clear coincidence between high levels of tuberculosis and the proportion of the female population employed in manufacturing, particularly at the youngest ages’ , and that ‘conditions in these jobs had, unlike domestic service, a deleterious effect upon the health of young people’ . 71 This effect was more noticeable in Belfast due to the higher participation of women in industrial occupations but it played a role, though a lesser one, in Dublin too. However men suffered from increasing levels of mortality from tuberculosis as a result of urbanisation and in most Irish towns and cities they had a higher mortality from the disease than women. Their mortality from TB was also characterised by the fact that it was higher among older men than older women. At the younger age ranges in most urban areas, mortality among women and girls was higher than men’s but around age twenty the mortality for women began to fall relative to that for men. More men were dying of tuberculosis than women (per 100,000) at later age ranges. 72 This holds true not only for Ireland. 73 The heightened susceptibility of younger women could be due to the physiological changes taking place at puberty. 74 It was also at that point in their lives that women were most likely to enter the labour 77

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones market and to be exposed to industrial or occupational environments conducive to the spread of consumption. 75 Men, however, remained within the labour market much longer and had prolonged exposure to the risks of infection in a wider variety of occupations. Some of the higher mortality from tuberculosis among older men was likely to be the result of a reactivation of a tuberculous infection contracted at a younger age but which had either been dormant or gone into remission. This reactivation of a previous infection might happen because of lifestyle: tobacco and alcohol consumption was more common among men in the nineteenth and early-twentieth century and this could adversely affect the general health of the individual. 76 However, the unskilled working-class male, who by the 1900s in Dublin had the highest mortality from phthisis of any group except the inmates of workhouses, was likely to experience periods of heavy labour, interrupted by unemployment, and to subsist on low wages. Moreover, for many of this occupational group social conditions as well as general health deteriorated appreciably in old age.

In the 1890s the population of Dublin and of her suburbs began to rise.77 Large scale industrial development played little part in this and Dublin’s industrial profile remained closer to that of London than Belfast. Its industries included dressmaking and tailoring, the service and retail sectors, building and construction, transport and the docks and domestic service. Some larger scale industries existed; the Guinness brewery , the bakeries, the tram, railway , docks and gas companies. There was a class of state employees in Dublin ranging from prison and police to the higher civil service and an important stratum of legal and medical professionals who made their home there. Among Dublin’s citizens there were those who had means but no occupation for Dublin was a city , like London, which had a ‘season’ during which a migratory upper-class was in residence. Dublin’s transient population also included students and the political classes who divided their time between London and Dublin. The growth of her suburbs meant a population of the inner city swollen in the day by commuters and at night by pleasure seekers. In times of economic distress Dublin’s population rose temporarily. In the opinion of many Dubliners, the city’s social and health problems were aggravated by the flow of the poorest agricultural classes into the capital during these periods of economic depression in the countryside. 78 The proportion of those living in Dublin but who were born 78

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II outside Dublin County was at its recorded highest in 1851 in the wake of the famine and in 1881 in the aftermath of the agricultural depression of 1879-80. For most of the rest of the nineteenth century the number of Dubliners born outside the county was around thirty percent rising only slightly between 1891 and 1901 and falling to 29.67 percent in 1911. 79 In 1936 it was still around 29.7 percent. 80 These figures were similar to those for London. 81 Some observers believed that a high proportion of these migrants to Dublin subsequently emigrated from Ireland altogether, to be replaced by another wave of migrants creating a constant inward and outward flow. 82 The other belief was that the typical immigrant into Dublin was poor and uneducated gravitating to low waged casual employment. In the words of Dublin Corporation in 1936, ‘we are satisfied that large numbers of persons come to Dublin seeking work, often without success, or with only temporary success, and that very many of them swell the ranks of the unemployed and drift into the slums’. 83 This was undoubtedly an exaggerated view, for migrants to Dublin included those seeking professional and business opportunities. 84 However, at the end of the nineteenth century and beginning of the twentieth, the proportion of the casual and unskilled in Dublin’s workforce was increasing. There were more unskilled labourers in the Dublin of 1900 than there had been twenty years earlier, partly as the result of the decline in older artisan occupation s. 85 Dublin’s population, according to Mary Daly , contained ‘ an abnormal proportion of casual workers and the consequent level of chronic under-employment’. 86 The growing numbers of the unskilled and semi skilled produced pressure on wages and accommodation. The 1914 report on Dublin’s housing stated that ‘In the last two decades the population within the city boundary has grown by no less than 20,648 and is now the highest since 1821 when the first census was taken.’87 The population of the inner city actually fell butdensity increased. In the inner Dublin area density per acre was 65.5 in 1891 and 71.1 in 1911. In the extended city created by the new boundaries drawn in 1900 it was 36.7 in 1901 and 38.5 in 1911. 88 Many of the Dublin poor within the inner city area were housed in tenements which the Royal Commission on the Housing of the Working Classes in 1885 described as the large vacated houses of the wealthy converted into accommodation for poorer families. 89 The Sanitary Act (Ireland) passed in 1878 provided for the demolition of the most insanitary and dilapidated of these and between 1880–1911 the percentage of Dubliners living in tenements dropped from 46.8 79

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access Greta Jones percent to 38.7. 90 Slum clearance, however, often aggravated the problem of overcrowding. In 1884 Charles Cameron surveyed for the Royal Commission on Housing, several streets in which manual workers employed by Dublin Corporation – by no means the poorest among Dublin’s population – were housed. The average number of people per house was 6.9. In 1901 the number of houses in these same streets had almost halved but the average number of persons per house was 5.9 only slightly below the 1884 figure. 91 There is evidence that housing conditions for the very poorest worsened over this period. In 1914 the investigation into Dublin’ s housing estimated that, whilst the number of Dublin’s tenements were fewer than in 1880, they now housed an average of 22 people per house as compared to 12 in 1880. 92 Moreover, the physical condition of the remaining tenements had deteriorated. Newsholme dealt with housing in his discussion of the rise of phthisis in Ireland but he discounted its role on the grounds of the overall improvement which had taken place in the nineteenth century. The proportion of one or two roomed dwellings of poor construction, typical of the cabins found in rural Ireland, had fallen dramatically whilst that of larger and better constructed dwellings had risen.93 Others took a similarly sanguine view. Belfast not only had superior housing for the working-classes to Dublin but also better housing conditions than many other industrial British cities yet in 1911 she still had a higher rate of mortality from phthisis than British cities with poorer housing. Glasgow was comparable with Dublin because of the extent of her tenement housing but, from some perspectives, Glasgow’s housing problem was more serious than Dublin’s. For example, in 1911 Glasgow had 53.6 percent of her population living more than two to a room compared with 37.9 percent in Dublin. 94 These figures, however, disguise the existence of a particularly disadvantaged section of the Dublin working-class population in regard to housing. Robert Matheson, Ireland’ s registrar general , argued that, according to the 1901 census, the number of one room tenements or dwellings with five or more occupants in every 100 dwellings of all classes was 8.69 percent in Dublin compared to 4.28 in Glasgow and the total percentage of the population living in one roomed tenements or dwellings with more than five occupants was 10.61 in Dublin compared to 5.24 in Glasgow, the next highest figure in the British Isles. 95 Thus the ‘tail’ of poor housing in Dublin was probably worse than anywhere in the British Isles. Neil McFarlane in his study of tuberculosis in Scotland argues that there was a close connection between overcrowding and 80

Greta Jones - 9789004333413 Downloaded from Brill.com09/28/2021 11:46:11PM via free access The Tuberculosis Epidemic in Ireland: II tuberculosis in Glasgow although he also believes that, with the exception of childhood tuberculosis, it was the number of persons per house rather than the number per room which raised tuberculosis mortality.96 This – the number per house – was, as we have seen, worsening in the poorer inner city areas of Dublin between 1890 and 1911 as was the density per square acre. As contemporaries pointed out, rents in Dublin were high but wages generally lower than in the rest of the United Kingdom. This produced a stratum of the very poorest, constantly in a state of crisis as regards housing, paying a high proportion of their uncertain income in rent and for whom general physical and sanitary conditions were poor. Just what this meant can be illustrated by the patients suffering from phthisis who attended Sir Patrick Dun ’s Hospital Dispensary in Dublin from 1904-8. Although the area served by the Dispensary contained the fashionable Merrion Square, it was otherwise a locality of poor working-class dwellings and tenements. It was common to find several families in one building. Among a selection of TB patients who attended the Dispensary and whose addresses can be checked in the census of 1901 or 1911, their accommodation consisted of 29 people in a 10 roomed house, a house of 9 rooms with 36 people, a 4 roomed house with 19 residents, an 8 roomed one with 26 and, to underline the problems of multi occupation, occasionally families of 6 and 7 persons living in one room and adjacent to other families of a similar size living in one room in the same building. 97 This led to multiple cases of tuberculosis often arising in proximity and, in turn, this led to the feeling among doctors and the public that there were certain addresses particularly prone to cases of consumption, ‘coffin houses’ as they were called. In the case of Sir Patrick Dun’s Hospital Dispensary, cases were recorded consecutively in Great Clarence Street at number 5, 3, 2, 11 and 29 in 1904, 1905 and 1907. Power’s Court saw a case at number 29 in 1905 and 32 in 1908 and Denzil Street a case at number 12 and at 33 in 1906, and number 35 in 1907. 98 The apparent recurrence of cases in certain vicinities led to the idea that the tubercule bacillus could survive in the walls and dust of badly constructed and insanitary houses making them particularly dangerous. 99 Overcrowding was, however , much more likely to be the precipitating cause of these multiple infections. 100 Similar cases of poverty and disadvantage existed in other Irish cities.101 In Belfast, for example, notifications of TB under the Tuberculosis Act (Ireland) of 1908, indicate broadly comparable social class and environmental determinants at work. 102 Between 81

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1908-16, 22 percent of all notifications among males were labourers and porters (410), the next largest categories were clerks (54) and linen workers (53). 103 The wards which had the highest level of notifications per 1000 inhabitants were those housing the poorer working-class family such as Smithfield in which dock worker’s and porter’s families lived and where, even in 1937, 25 percent of families were sharing houses. 104 However, Belfast did not have as large a stratum of the casual and unskilled as Dublin and its occupational structure, dominated by textiles and, by 1911, shipbuilding and engineering, led to a greater degree of workplace and residential segregation between the middle and working-class. 105 There were very poor and disadvantaged people in Belfast but Dublin’s hawkers, van and cab drivers and labourers were much more a feature of the city and its day to day social encounters.

The tuberculosis epidemic in Ireland was the product of economic development: in the case of Belfast and its hinterlan d, industrialisation which caused a rapid expansion of its population in the mid and late-nineteenth century; in Dublin’s case, growth at the turn of the century linked to commercial rather than industrial development. The consequences of this – in the industrial and urban environment, in housing and in the creation of a stratum of the very poor in the city and in changing patterns of rural migration – all contributed to raising phthisis rates. Ireland’s tuberculosis epidemic suggests that, although a fall in female mortality accompanying urbanisation might be true in the long term, given the experience of women in Belfast and other linen areas of the north east, this is contingent upon the particular circumstances of industrial and urban development and that it may not hold true at all stages of an epidemic. The fact that an epidemic of tuberculosis was taking place in a country in which the population was falling overall and which was still primarily rural, did not appear to inhibit the rise in tuberculosis mortality. France was still a rural country in 1900 with a population which was stagnant or rising relatively slowly in comparison to other western European countries but she too had a serious tuberculosis problem, particularly in urban areas. So too had Norway. She was also predominantly rural and had a high rate of emigration. However, between the 1860s and 1900s, the percentage of her urban population grew. Oslo doubled its population between 1858 and 1908. During the same period Norway’s tuberculosis problem worsened. 106 82

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National comparisons can, however, be taken too far. What emerges from Ireland’s TB epidemic is the extent to which factors unique to the economic and social circumstances of an area affect the rate of mortality from tuberculosi s and the groups affected. Differences exist even within national boundaries. There were particular characteristics to the tuberculosis epidemic in Belfast compared to Dublin, and no doubt repeated to smaller extent in other Irish towns outside the two major conurbations. In the case of Belfast, industrial conditions bore particularly hard on women; in Dublin urbanisation and the persistent problem of a low-waged, badly-housed, poor, often under-employed class, exacerbated the problem there. These influences, however, took place alongside many other forms of social contact which aided the spread of the disease. Even the tuberculosis history of the smaller textile towns of the industrial north east, largely dominated by the introduction of the mill, are complicated by, among other things, the everyday contact and movement of men and women in their work, trips back and forth between the rural hinterland and to and from Belfast and by migration into these towns, some of it from outside Ireland, in the early stages of the development of linen. Different urban experiences also account for the way in which tuberculosis was perceived. The commentary on it in Belfast at the height of the epidemic was suffused with the shock of the factory, not just the conditions inside it, but the change in social relations it had brought about. A sudden deterioration in the environment had accompanied its arrival and what seemed like new and dangerous habits – early marriage, decline in religious observance and, linked to the employment of women in the factory, changes in the domestic regime. Discourses on the avoidance of phthisis were therefore about the reintroduction of order and control in these areas. By the 1900s, however, the factory was a symbol of prosperity and stability and some defended it against its reputation as a cause of the spread of phthisis. In Dublin, by contrast, it was social anxieties about the residuum, the increasing urgency of the problem of the very poorest, which textured the response to the problem of consumption.

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Appendix 1

Tuberculosis Deaths in the Chief Towns of Ireland 1871–1910 per 100,000 living persons (Phthisis Only)

1871-80 1881-90 1891-1900 1901-10 Belfast 382 372 340 263 Dublin North334 363 321 } Dublin 447 County Dublin South300 346 350 } Borough Cork 274 294 336 299 Limerick 207 238 250 270 Waterford 277 269 281 293 Lisburn 299 307 264 271 Lurgan and Portadown 235 322 252 – Londonderry240 202 209 – Newry 243 249 236 – Sligo 190 206 214 –

Source:Decennial Report of Registrar General (Ireland), 1911

Appendix 2

Annual Death Rates from Phthisis per 100,000 Among Males and Females England and Wales

Males Females 1851-60 270 290 1861-70 260 260 1871-80 240 210 1881-90 200 170 1891-1900 160 120 1901-10 140 100

Source: Gillian Cronje, ‘Tuberculosis and mortality decline in England and Wales 1851-1910’ in R Woods and J Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England , London, Batsford, 1984, pp. 79-101, Table 4.4, 86.

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Male and Female Differential in Ireland. Pulmonary TB Only. Deaths per l00,000 per Living Persons

Male Female Total

1861-70 217 220 218.9 1871-80 191 199 195.57 1881-90 197 220 209 1891-1900 204.6 221.9 213 1901-10 200 204 202

Source: Calculated from the Decennial Summaries of the Registrar General (Ireland) 1871-1910 and Census of Ireland, 1871 Part 11 Vital Statistics, Vol 1 Report and Tables relating to the Status of Disease.

Notes 1. John Brownlee, An Investigation into the Epidemiology of Phthisis in Great Britain and Ireland , MRC Report No. 18, (1918), 14. 2. See Appendix 1. 3. T. W. Grimshaw, ‘The Prevalence and Distribution of Phthisis and Other Diseases of the Respiratory Organs in Ireland’, Transactions of the Royal Academy of Medicine in Ireland , vol. V (1887), 314–39, Table 11 pp. 318–22. Newtownards had a phthisis rate of 317 per 100,000 persons for the period 1871–81, Lisburn 308, Banbridge 290, Lurgan 285. In North and South Dublin it was 317 and Belfast 382. Only Navan of the rest of the medical superintendent’s districts had a phthisis rate above 285. 4. T. W. Grimshaw, ‘Observations on the relative prevalence of disease and the relative death rates in town and country districts in Ireland.’, Transactions of the Academy of Medicine in Ireland , vol. III, (1885), 328–404. A civic union is defined by Grimshaw as an area with a municipal government and a population of 10,000 and over. For the three years 1895–7 the respective phthisis rates for civic unions was 339, and for rural 170. See T. W. Grimshaw, ‘The Prevalence of Tuberculosis in Ireland and the Measures necessary for its Control’, Dublin Journal of Medical Science vol. CVII (1 March 1899), 161–265. 5. See the Decennial Report of the Registrar General, (1901), 37. 6. H. E. Counihan and T. W. T. Dillon, ‘Irish Tuberculosis Death Rates’, Journal of the Statistical and Social Enquiry Society of Ireland vol. XVII (October 1943), 169–88.

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7. W. E. Vaughan and A. J. Fitzpatrick using the percentage of the population living in towns of 2,000 and above, give the figures as 13.89 in 1841, 19.36 in 1861 and 31.06 in 1901. Irish Historical Statistics.Population 1821-1971 (Dublin: Royal Irish Academy, 1978), 27. 8. Population Year Belfast Dublin 1841 75,308 232,726 1861 119,393 246,465 1901 349,180 290,638 1911 386,947 304,802 Source: Vaughan and Fitzpatrick, ibid., 28–41. In the case of Dublin the City boundaries were extended in 1900. Population in the central area of Dublin fell though suburban and dormitory areas adjacent to Dublin were growing at this time. 9. Calculated from Decennial Report of the Registrar General (Ireland) 1911 Table XVII. Dublin County Borough and Dublin City are counted together. 10. See Appendix 1 11. Gillian Cronje, ‘Tuberculosis and Mortality in England and Wales 1851-1910’, in Robert Woods & John Woodward (eds), Urban Disease and Mortalityin Nineteenth-century England (London: Batsford Academic and Educational, 1984), 79-101. Cronje notes high rates for both sexes in North Wales, males in Sussex and females in Suffolk and Cumberland, 97. 12. William Johnston, The Modern Epidemic. A History of Tuberculosis in Japan (Harvard, Mass.: University of Harvard Press, 1995), 66. He links the high rates to the fact that these rural areas provided women for the textile industry and that they returned to them spreading the disease. 13. R. C. Geary, ‘Mortality from Tuberculosis in Saorstat Eireann ’, Journal of the Statistical and Social Inquiry Society of Ireland vol. XIV (October 1930), 67-103: 98. 14. Linda Bryder discusses the high tuberculosis rates in North Wales in the context of the slate industry there, in Below the Magic Mountain: A Social History of Tuberculosis (Oxford: Clarendon Press, 1988), 126. 15. L. A. Clarkson, ‘Population Change and Urbanisation 1821-1911’, in Liam Kennedy and Philip Ollerenshaw (eds), An Economic History of Ulster, 1820-1939 (Manchester: Manchester University Press, 1985), 138–9. 16. At the height of the Belfast cotton industry c.1834 there were 86

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around 2,960 cotton operatives and 2,300 working in flax. The largest number of cotton mills in Belfast was 21 in 1826. See F. Geary, ‘The Rise and Fall of the Belfast Cotton Industry. Some Problems’, Irish Economic and Social History vol. 8, (1981), 30–49, pp.32-3 and Table 1, 35. 17. Emily Boyle, The Economic Development of the Irish Linen Industry 1825-1913 (unpublished Ph.D. Queens University Belfast, 1979), 146. 18. Mary E. Daly, Women and Work in Ireland , Studies in Irish Economic and Social History no. 7 (Dublin: Economic and Social History Society, 1998), 33. 19.The Census records around thirty percent of women as having a recorded occupation in the four provinces of Ireland in 1881, a percentage which declines to around twenty-five percent by 1891. The employment of women under 20, however, shows a slight increase in all provinces in 1891 while the proportion over 20 recorded as employed declines. This is in accord with the tendency noticed in England and Wales for married women to drop out of the labour market towards the end of the century. See Census of Ireland for 1881 Connaught vol. LXXIX, 623; Munster vol. LXXVII, 1002; Leinster vol. XCVII, 1191; Ulster vol. LXXVIII, 972. Census of Ireland 1891 , Leinster vol. XCV, 1191; Connaught vol. XCIII, 623; Munster vol. XCI, 1002; Ulster vol. XCII, 972. (Calculated as a percentage of the total recorded in paid occupations for that period and province.) The census, of course, fails to record the amount and extent of female economic activity and therefore cannot be taken as a definitive statement of the degree to which women were involved in the economy. The highest recorded employment of women is in Ulster.

Stated Occupation of Women in the Province of Ulster 1881

Domestic Service111,731 Agriculture 34,115 Textile 69,891 Dress 62,832

Source: Census of Ireland for 1881 vol. LXXVIII, 972.

In all the other provinces of Ireland 67,598 gave their stated occupations as textiles or dress and of these the vast majority, 55,378, were in dress. In Dublin in 1901 the total number of females in the combined trades of dress and textiles was 27,333 compared to 71,915 in domestic service. See Census of Ireland 1901 , 9. 87

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20. Mary Daly, op. cit. (note 18), 34–5. 21. ‘ The dwelling accommodation seems to have kept pace with the population; in consequence of the continual building which is going on, there has been no difficulty in rehousing the population displaced by the extensive improvement schemes. Belfast being an entirely new town, there are not many houses inhabited by the working-class which were originally intended for richer people and the tenement house is scarcely found at all. The rule is that houses are built for only one family’, Report of the Commission of Inquiry into the Housing of the Working Class (Ireland) PP1884-5 vol. XXXI, Cd 4547, viii. 22. Whilst Mary Daly argues that the combined wages of an unskilled male labourer and those of a female linen operative were only the equivalent of a skilled working man’s wage, in terms of family income this was significant. See Daly, op. cit. (note 18), 33. 23. ‘Summary of Statistics on Tuberculosis prepared by the Local Government Board of Ireland for the International Congress on Tuberculosis in Washington’, in Ishbel Maria Gorden, Marchioness of Aberdeen and Temair (ed.), Ireland’s Crusade against Tuberculosis: being a series of lectures delivered at the Tuberculosis Exhibition, 1907, under the auspices of the Women’s National Health Association of Ireland, (Dublin: Maunsel & Co., 1908), 3 vols, vol. 1, 173. 24. Henry Patterson, ‘Industrial labour and the labour movement’, in Liam Kennedy and Philip Ollerenshaw, op. cit. (note 15), 165–9. 25. See Appendix 2. 26. For Northern Ireland in 1926 there was a tuberculosis mortality rate per 100,000 of 140 for males and 153 for females: by 1937, after a decade in which the two figures a gradually converged, it was 100 for men and 95 for women and by 1952 35 for men and 25 for women: see Registrar General for Northern Ireland AnnualReport for 1952 in the volume containing the 31st–35th Annual Reports, 21 Table K. In Saorstat Eireann male rates were still marginally lower in the 1920s but by the 1940s the male rate was higher: see MRC of Ireland, National Tuberculosis Survey, Tuberculosis in Ireland , (Dublin, 1954), Table 2, 27. 27. Gillian Cronje ‘Tuberculosis and Mortality in England and Wales 1851-1910’, in Robert Woods & John Woodward (eds), Urban Disease and Mortalityin Nineteenth-century England (London: Batsford Academic and Educational, 1984), 79–101: 85, Table 4.2. 28. John Guy wrote of this phenomenon in 1923: ‘It is an elementary truth to those who have studied this disease that more men die of tuberculosis than women. This disparity is more marked in urban 88

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communities than in rural.’ John Guy, Pulmonary Tuberculosis , Edinburgh: Oliver and Boyd, 1923, 10. See also Arthur Newsholme ‘Public Authorities in Relation to the Struggle against TB’, Journal of Hygiene vol. 3 (1903), 447–67, Table 11, 447. 29. Cronje, op. cit. (note 11). Why this should be so has been discussed by Sheila Ryan Johansson, ‘Sex and Death in Victorian England. An Examination of Age and Sex Specific Death Rates, 1840-1910’, in Martha Vicinius (ed.), A Widening Sphere. TheChanging Roles of Victorian Women (Bloomington: Indiana University Press, 1977), 163–81. Johansson suggests that social and economic inequality between the sexes may have lessened in some, though not all, nineteenth century urban environments. Because young urban women could obtain work outside the household their general nutritional condition improved. Improvements in the domestic environment towards the end of the nineteenth century may also have helped. Whilst these factors cannot be discounted, this study suggests the work environment experienced by women may have led to a short term rise in their mortality from pulmonary tuberculosis. 30. The comparative male/female death rate for all of Ireland is available as it is for the provinces. However working out the male/ female death rates for rural areas is more difficult. It has been done for the twentieth century and this shows the classic higher female death rate for women in rural areas. See Donnell Deeny, Tuberculosis in Ireland, A Thesis Presented for the Degree of Doctor of Medicine (Queen’s University Belfast, 1945). He gives the figures for Northern Ireland, 1929–38, as in urban areas 129 for males and 111 for females and in rural 91 for males and 108 for females. James Deeny also shows an similar urban/rural disparity 1939–49 for the twenty-six counties of Saorstat Eireann . See Tuberculosisin Ireland , National Tuberculosis Survey for the Medical Research Council of Ireland (1954), Table 2, 27. 31. See F. B. Smith, The Retreat of Tuberculosis 1850-1950 (London: Croom Helm, 1988), 10–11 and also Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800-1950 (Oxford: Clarendon Press, 1992), 30–31. 32. H. W. Bailie, Report of the Belfast Health Commission to the Local Government Board (Ireland) (known as the Belfast Health Commission) PP 1908 vol. XXXI Cd 4128, 23 Table XIV. 33. Registrar General of Ireland Decennial Summaries 1871-1910, xiviii, Table XXVII. 34. For example, Irish doctors may have classified infant deaths differently. Deaths attributed to convulsions and ‘wasting’, for 89

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example, may have been tuberculous. Birth registration in rural areas throughout the British Isles was low in this period and the 1907 Registration of Births Act did not make registration of births compulsory for rural areas in Ireland. 35. See J. F. O’Sullivan, The History of Obstetrics in Northern Ireland 1922-1992 (unpublished Ph.D. thesis, Queen’s University of Belfast, 1996) and personal communication from the Vital Statistics Section of the Central Office of Statistics, Dublin. 36: Maternal Mortality per 1000 live births

England & Wales Ireland Other Causes All Causes Other Causes All causes 1901 2.7 4.7 3.9 6.18 1904 2.2 3.8 3.5 5.6 1911 2.4 3.87 3.2 5.05 1920 2.5 4.3 2.8 4.87 1930 2.3 4.4 3.8 4.77 excl.N. Ireland 1939 2.0 2.8 2.7 3.39excl. N. Ireland

Source: Loudon Death in Childbirth, op. cit. (note 31), Appendix 6 Table 1 and 4, 542–50. 37. TB has little or no effect on the chances of contracting puerperal sepsis, a main cause of death in childbirth, nor did maternity make a woman more susceptible to contracting TB. Ibid., 31 and also Irvine Loudon personal communication. 38. Decennial Summaries 1871–1910 , op. cit. (note 33), xlii Table XXII. 39. Using Vaughan and Fitzpatrick’s definition of civic population as percentage living in towns of 2,000 persons or more, the most urbanised provinces respectively are indicated on a scale of 1-4, 1 being the Province with the highest percentage of civic population.

Male and Female death rate from TB (all forms) per 100,000 persons in the four provinces of Ireland averaged for the decades 1861-70, 1871-1881 and for the year 1911.

1861–71 1871–1881 1911 M.F.M.F.M.F.

Leinster 304 292(1) 294 279(1) 268 253(1) Munster 172.7 165(2) 223 215(3) 213 210(3) Connaught 131 137(4) 260 242(4) 157 157(4) Ulster 227 249(3) 274 301(2) 201 232(2) 90

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Source: Calculated from W.E. Vaughan and A.J. Fitzpatrick Irish Historical Statistics,Population 1821-1971 (Dublin: Royal Irish Academy 1978), 16–17. TB statistics calculated from the Census and the Decennial Reports of the Registrar General for Ireland. 40. A certifying surgeon was appointed under the Factory Acts to medical examine child entrants to factories and report on the enforcement of sanitary legislation. 41. C. D. Purdon, Mortality of Flax Mill andFactory Workers and the Diseases they Labour Under. Read to the annual meeting of the Association of Certifying Medical Officers of Great Britain and Ireland at Leeds 19 September 1873, 4. In the pamphlet collection in the Linenhall Library, Belfast. 42. C.D. Purdon, The Sanitary State of the Belfast District during Ten Years 1864-73 , (Belfast: H. Adair, 1877). Pamphlet Collection, Linenhall Library, Belfast. 43. See Robert A. Newett, Address to Mill Workers on the Prevalence of Consumption Among Them 1875, Pamphlet Collection, Linenhall Library, Belfast. Newett was medical officer for Ligoniel, a suburb of Belfast with a high concentration of linen workers. 44. E. H. Osborn, Report Upon the Conditions of Work in Flax Mills and Linen Factories in the United Kingdom , PP 1893-4 vol. XVII. C. 7287. 45. H. W. Bailie, Report of the Belfast Health Commission to the Local Government Board (Ireland) (known as the Belfast Health Commission). PP 1908 vol. XXXI Cd 4128, Table XI, 17. The zymotic diseases included small pox, measles whooping cough, scarlet fever, diphtheria, typhus, enteric fever, pyrexia, diarrhoea. 46. Ibid., Table XXI, 35. The differential between Belfast and Manchester was from age 10–15 1.1: 15–20 3.5: 20–25 2.9: 35–35 2.3 and 35–45 0.5. 47. Sheila Ryan Johansson, ‘Sex and Death in Victorian England, An Examination of Age and Sex Specific Death Rates, 1840-1910’, in Martha Vicinius, A Widening Sphere. TheChanging Roles of Victorian Women, op. cit. (note 29), 180, Table 8. 48. Ibid., 37. 49. Report of the Joint Public Health, Works and Market Committees of the Belfast Corporation upon the Report of the Belfast Health Commission. Public Record Office of Northern Ireland LA7/9DB/1, 8. 50. David Rosner and Gerald Markowitz argue a politico-medical struggle took place in the late-nineteenth and twentieth century to deny the contribution of industrial conditions to illness. They regard 91

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tuberculosis as a casualty of this. See David Rosner and Gerald Markowitz, Deadly Dust.Silicosis and the Politics of Occupational Disease in the Twentieth Century (New Jersey: Princeton University Press, 1991), 14 and 18. 51. Evidence of J. A. Lindsay in Report of the Commissioners, Inspectors and Others on Humidity and Ventilation in Flax and Linen Factories , PP 1914 vol. XXXVI Cd. 7448. Minutes of Evidence , Cd 7433, 24. Lindsay was a eugenicist though he did not share Karl Pearson’s views about about the hereditary nature of tuberculosis. See Greta Jones, ‘Eugenics in Ireland: The Belfast Eugenics Society’, Irish Historical Studies vol. xxviii no. 109 (May 1992), 81–95. 52. Report of the Commissioners, Inspectors and Others on Humidity and Ventilation in Flax and Linen Factories,ibid. , 31. 53. Temperatures of around 95-111 ºF were recorded in the dry spinning sections of the linen mill in the nineteenth century and, in the 1870s, of between 72-86 ºF. in the wet spinning. These temperatures did not show much reduction in 1914. See Report of the Commissioners, Inspectors and Others on Humidity and Ventilation in Flax Mills and Linen Factories , op. cit. (note 51), 53, Table 3. Wet spinning, in addition, had very high humidity and water from the process often soaked the workers and the factory floor necessitating the removal of shoes. Osborn, in his investigation of Belfast mills, noted in 1892, ‘In one shed visited after 5 pm, where saturation prevailed and the steam was blowing at full blast, the place was so filled with vapour it was impossible to see half way its length; the jets were directed downwards impinging upon the bodies of the weavers and the garments they would go home in...’ Report of the Conditions in Flax Mills and Linen Factories 1893-4, op. cit. (note 44), 541. 54. The Factory Inspectorate considered that the floor and air space provided for cotton and linen operatives was roughly the same but a linen shed of 500 looms would contain around 250-300 workers whereas a cotton shed of similar size around 200. The Committee on Humidity and Ventilation believed that the level of humidity in linen sheds was generally greater than in cotton sheds once the temperature rose above 70 ºF. See Report of the Commissioners, Inspectors and Others on Humidity and Ventilation in Flax Mills and Linen Factories , 1914, op. cit. (note 51), 50–3. 55. It is probable that an increase in the size of a working environment affected everyone regardless of gender. In 1949 Alice Stewart and J. P. W. Hughes observed a correlation between size of factory floor and the incidence of pulmonary TB among boot and shoe operatives 92

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in Northamptonshire. These workers had a higher incidence of TB than other trades and the researchers believed that, while the standard of health of the workers in this industry was below average, the size of factory was the most important factor in accounting for the level of infection. See Alice Stewart and J. P. W. Hughes ‘Tuberculosis in Industry; An Epidemiological Study’, British Medical Journal vol.1 (May 1949), 926–9. In her work on tuberculosis in England and Wales Gillian Cronje discusses the research done by Margaret Cairns on tuberculosis in the boot and shoe industry. Uniquely, workers in this industry showed a rise in mortality for pulmonary tuberculosis towards the end of the nineteenth century at the same time as it declined in England and Wales as a whole. The rise experienced in the industry is seen by Cairns as the consequence of the movement from small scale domestic production to the factory. See Margaret Cairns, The History of the Boot and Shoe Industry and its Relation to Social Conditions including a Comparison with other Industries (unpublished Ph.D. thesis, University of Oxford, 1953). Discussed in Gillian Cronje Pulmonary Tuberculosis in England and Wales , (unpublished Ph.D., University of London, 1990). 56. Mary E. Daly, op. cit. (note 18), 30–7. 57. Donnell Deeny, A Survey ofT uberculosis in Northern Ireland (thesis presented for the degree of doctor of medicine, Queens University Belfast, 1945). By the 1930s the male tuberculosis death rate was higher in Northern Ireland than the female. Because of the inter war depression in textiles, there were fewer women working in the mills which may also have contributed to the decline in the tuberculosis death rate among females. 58. William Johnston, op. cit. (note 12), 74–90 Tables 4 and 5. 59. Ibid., 82–90. 60. Dr John McIlwaine, the certifying surgeon for some of Belfast’s linen mills, admitted to the committee on ventilation and humidity in 1914 that he had not read the wet and dry bulb thermometers measuring heat and humidity until ten days before giving evidence and was surprised to find them so high. Report of the Commissioners and Others on Ventilation and Humidity in Flax and Linen Factories , op. cit. (note 51), Minutes of Evidence, 143, paras. 116–19. See also the discussion in Linda Bryder, ‘Tuberculosis, Silicosis and the State Industry in North Wales’, in Paul Weindling (ed.), The Social History of Occupational Health (London: Croom Helm, 1985), 108–26. Similar political and economic imperatives operated in this industrial sector to obscure the part played by industrial conditions in the 93

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spread of the disease. 61. Resolution from Messrs John Brown, Lower Lodge Factory in Report of the Commissioners and Others on Ventilation and Humidity in Flax and Linen Factories , op. cit. (note 51), 35. In contrast the committee was told that a motion in favour of industrial action had been passed in Lancashire over the humidity issue by a vote of 60,000 to 3,000. Evidence of William Gordon, manager at Herdman’s Ltd, ibid., 96, paras. 3498-3299. 62. Purdon, op. cit. (note 42), 4. 63. The advice tendered by Purdon emphasised domestic cleanliness, a nutritious diet and urged women workers – who shed clothes in the heat of the mill – to cover themselves when leaving to avoid chills. Robert A. Newett, op. cit. (note 43), elaborated on similar themes and also pointed to the scanty and insufficient clothing of female mill hands working in the hot and humid conditions of the mills. 64. See Appendix 1. 65. See the discussion in Sheila Ryan Johansson, ‘Sex and Death in Victorian England, An Examination of Age and Sex Specific Death Rates, 1840-1910’, in Vicinius, op. cit. (note 29), 175–6 and Mary E. Daly The Deposed Capital, (Cork:Cork University Press, 1984) Table IV, 245. 66. R. C. Geary, op. cit. (note 13), 80. The figures are 181 per 100,000 for men and 165 for women in Dublin. In the rest of Ireland it was 113 for men and 121 for women and for the three other county boroughs it was 165 for men and 158 for women. 67. The Appendix on Health for the 1871 census contains an analysis of the deaths from consumption from 7 April 1861-April 1871 by occupation. Given that registration must have been unsatisfactory in many respects and, in some cases, the sample was too small to be significant, a few interesting figures emerge on male and female differences with regard to mortality from consumption. Among female dressmakers 40 percent of the total number of deaths were from phthisis. The next largest percentage is 35 percent of male tailors who died died from phthisis (which, if female tailors are included, drops to 33 percent of the total in that trade), followed by printers 34 percent and male clerks 30 percent. There are mortality rates for phthisis among workers in metals, leather, wood and stone of between 25–29 percent. For women 27 percent of deaths of servants were from consumption. For the increasing numbers of women employed in dress towards the end of the nineteenth century see Daly, op. cit. (note 65), 42–3. 68. Daly, ibid. 69. Calculated from the social class tables of mortality in the yearly 94

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reports of the state of public health in Dublin Corporation Reports and Decennial Report of the Registrar General of Irelandfor 1911 . 70. Daly, Women and Work in Ireland , op. cit. (note 18), 31 on domestic servants in Dublin and their rates of pay. 71. Gillian Cronje, Pulmonary TB in England and Wales (unpublished Ph.D. thesis, London School of Economics, 1990) Table 4.12, 270. 72. This is confirmed in analysis of mortality from tuberculosis by age in the Registrar General’s Reports, the Belfast Health Commission and elsewhere. 73. See the calculations for the United States showing this age distribution in Arnold R. Rich, The Pathogenesis of Tuberculosis Oxford: Blackwell 1951, Table XII, 220. John Crofton and Andrew Douglas, Respiratory Diseases (Oxford: Blackwell Scientific Publications, 1981) 3rd edn., also discuss the influence of age on the distribution of tuberculosis mortality between men and women. 74. Crofton and Douglas, ibid., 234. 75. The highest proportion of employed women recorded in the nineteenth century census was in the younger age ranges, the proportion of married women employed outside the home tending to fall towards the end of the century. 76. Crofton and Douglas Respiratory Diseases , op. cit. (note 73), 234. 77. Mary E. Daly, op. cit. (note 65), Table l, 3.The increase led to a revision of Dublin’s boundaries in 1900 which increased the acreage by 4,125 and the population by 26,000. Daly, ibid., 236. 78. In 1914 a report on Dublin’s housing problem claimed, ‘Dublin in common with most other urban areas in this country has been affected by a gradual influx of population from the country areas’. Report of the Departmental Committee appointed by the Local Government Board (Ireland) to Inquire into the Housing Conditionsof the Working Classes in the City of Dublin , PP 1914 vol. XIX Cd. 7273, Minutes of Evidence Cd. 7317, 8. 79. Daly, op. cit. (note 65), 4, Table V. 80. Report of the Local Government Tribunal (Dublin) , Eire, Department of Local Government and Public Health (1944), 21. 81. Anne Hardy, The Epidemic Streets. Infectious Disease and the Rise of Preventive Medicine.op. cit. (Oxford: Clarendon Press, 1993) . Table 8.3, 224. 82. This was also the popular belief in Cork. The population of Cork City declined in this period and, ‘Contemporaries believed that the level of population in Cork City was maintained only through the constant inflow of country people.’ They replaced those who had emigrated and subsequently became emigrants themselves. See 95

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Maura Murphy ‘The Working Classes of Late Nineteenth-Century Cork’, Journal of the Cork Historical and ArchaeologicalSociety vol. 85 (1980), 26–51, 27. 83. Report of the Local Government Tribunal (Dublin) , op. cit. (note 80), 21. 84. See M. E. Crowley, ‘A Social and Economic Study of Dublin 1860- 1914’, Irish Economic and Social History, vol. 1 (1974) , 63 (Ph.D. abstract). Crowley says migrants to Dublin were mainly middle-class but he also says that the migration to Dublin of the unskilled working-class in the 1890s and 1900s led to pressure on wages and accommodation. 85. Daly, op. cit. (note 65), 66–7. This view is supported by Peter Murray Citizenship, Colonialism and Self Determination, Dublin in the United Kingdom 1885-1918 (unpublished Ph.D., Trinity College Dublin, 1987), 54. 86. Daly, ibid., 77. 87. Report of the Departmental Committee appointed by the Local Government Board (Ireland) to look into the Housing of the Working Classes in the City of Dublin, 1914, op. cit. (note 78), 9. Overcrowding in London at the end of the nineteenth century, measured by density per acre and a rise in persons per house, increased in the inner city though by no means as much as Dublin. However, tuberculosis was on the decline there. 88. Density per acre was 38.53 for Dublin City and County Borough, 28.6 for Cork and 25.9 for Belfast. See Census of Ireland1911. 89. Report of the Commission of Enquiry into the Housing of the Working Classes (Ireland) , PP 1884-5 vol. XXXI Cd. 4547, vi, ‘there are certain portions of the city which were formerly wealthy and fashionable which are now inhabited entirely by the poor’. 90. Between 1880-1911 over 4,000 tenements had been demolished or abandoned. Report of the Departmental Committee of the Housing of the Working Classes in the City of Dublin 1914, op. cit. (note 78), 6. 91. Charles Cameron ‘Lodging, Accommodation, Rent and Earnings in the Case of Manual Workers employed by the Public Health Committee’ in Report of the Commission of Enquiry into the Housing of the Working Classes (Ireland) , PP 1884-5 vol. XXXI Cd. 4547, Appendix A, 101. The subsequent comparison has been done by examining the same streets using the 1901 Census. 92. Report of the Departmental Committee into the Housing Conditions on the Working Classes in the City of Dublin , op. cit. (note 90), 6. 93. Arthur Newsholme, ‘Poverty and Disease as illustrated by the course of Typhus Fever and Phthisis in Ireland’, Presidential Address to the 96

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Epidemiological Section of the Royal Society of Medicine (25 October 1907). See Proceedings of the Royal Society of Medicine vol. 1 part 1 (1907-8), 1–44: 23–4. 94. Newsholme, Elements of Vital Statistics (London: Allen and Unwin, 1889) Rewritten and republished in 1923. 1923, 308. The rates, based on the 1911 census, were as follows: Percentage of the Total Population Phthisis Death Rate Living More than 2 to a Room Per 100,000 of the Population Belfast 5.5 252 Manchester 7.0 156 Liverpool 9.5 160 Birmingham 9.8 114 London 16.8 135 Edinburgh 31. 196 Dublin 37.9 280 Glasgow 53.6 147

95. R. E. Matheson ‘The Housing of the People of Ireland during the period 1841-1901’, Journal of theStatistical and Social Enquiry Society of Ireland , vol. XI (November 1903), 196–212: 211. 96. Neil McFarlane, ‘Hospitals, Housing and Tuberculosis in Glasgow 1911-1951’, Social History of Medicine , vol. 2 no. 1 (1989) 59–85: 78–79. 97. Information on the tuberculous patients (1,388 patients were seen during the period 8 August 1904–2 October 1908 of which 83 were consumptive) is taken from the Sir Patrick Dun’s Hospital Dispensary Medical Register 1904-8 in the possession of the Royal College of Physicians in Ireland and calculated for the address given by the patient traced in either the 1901 or 1911 census. The nineteen addresses of consumptives for which information can be found accommodated 70 households in 131 rooms comprising 335 people. 98. Ibid., Sir Patrick Dun’s Hospital Dispensary Medical Register. 99. Crofton and Douglas argue it can survive in bright sunlight for only about five minutes although longer in darker environments: John Crofton and Andrew Douglas, Respiratory Diseases (Oxford: Blackwell Scientific Publications 1981), 3rd edn., 229. 100. James Deeny, chief medical adviser to Saorstat Eireann from 1944, showed a similar interest in the clustering of TB cases in certain localities: see James Deeny, ‘A Study of Slow Motion Contagion. The Spread of Tuberculosis in an Irish Town’, Journal of the Medical Association of Eire (Deeny Papers, Royal College of Surgeons, December 1947). Critics of his view argued that the clusters occurred 97

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randomly although R. C. Geary, the Irish government’s chief statistician, sprang to his defence (letter of 28 April 1958, Deeny papers ibid.). In fact recent research involving DNA tracking of the TB bacillus also show loci of multiple infection clustering around and then radiating from certain addresses. These tend to be houses which accommodate a transient and disadvantaged population. (See the paper by Peter Small, Stanford University, on the ‘Molecular Epidemiology of Tuberculosis’ at the Conference on ‘Tuberculosis Then and Now’ held at the University of California, San Francisco, 7–8 April 1995.) 101. A survey of the addresses for those admitted to the Cork workhouse infirmary for tuberculosis between 1888-1901 shows a similar level of overcrowding to that in Dublin. The 38 addresses surveyed supported 90 households, a total of 375 people in 188 rooms. Calculated from Cork Workhouse Infirmary Register and the Census of Ireland for 1891 or 1901. 102. Notification levels are not a reliable guide to the social class incidence of TB because the better off often evade or escape notification. But they do provide some insight into the pattern of notification within the working-class. As might be expected for Belfast female notifications exceed male and the chief occupations given for women notified are housewife 32.5 percent (837) and mill worker 29.4 percent (757). The greater preponderance of women notified may, however, relate to the reluctance of male breadwinners to come forward as well as to the overall difference between the mortality of men and women from pulmonary tuberculosis in Belfast. Calculated from the Report of the Chief Tuberculosis Officer for Belfast County Borough for all years from 1908–16 except 1910. 103. Ibid. Report of the Chief Tuberculosis Officer for Belfast County Borough for all years from 1908–16 except 1910. For a chart on the geographical distribution of notifications in Belfast see ibid., 1917–18, 17. 104. Smithfield was near the docks and the markets and casual unskilled workers such as porters and dockers lived there. The figures for housing in 1937 are from J. F. O’Sullivan, The History of Obstetrics in Northern Ireland 1922-1948 (unpublished Ph.D. thesis, Queen’s University of Belfast, 1996). 105. The Reports of the Registrar General on Belfast, unlike Dublin, do not have anything approaching a social class breakdown of mortality. The Census of 1911 which designates individuals by trade and economic sector rather than level of skill or social position show that textiles remained the largest occupational 98

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sector in the city. 106. The percentage of the population which was urban rose from 10.8 in 1835 to 23.7 in 1890. T. K. Derry, A History of Modern Norway 1814-1972 (Oxford: Clarendon Press, 1973), Table II, 97–8.

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