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The Tuberculosis Epidemic in Ireland:I

The basis for modern statistical knowledge about mortality and health was laid in the nineteenth century. This has widened the information available to historians but also presented them with a new set of problems. The early attempts at collection of medical data, initially based upon door to door surveys and later upon returns of registered births and deaths, were not always complete or accurate. Modern historians often ask different questions to those posed by the officials who collected medical statistics in the nineteenth century. Finally the collection of official statistics took time to establish itself, to become part of bureaucratic routine and a generally accepted civic duty in the population at large. In 1841 William Wilde was the medical adviser to the census and in 1851, 1861 and 1871 he was a medical commissioner. Each of the decennial censuses in Ireland from 1841 to 1871 in which Wilde played a part, contained a chapter on the mortality and health of Irish people. His investigation was conducted in several ways, by an analysis of the sick in public institutions, and by a house to house survey which recorded recent deaths in the household and anyone currently sick. In 1851 his investigation included an analysis of Dublin divided into districts by wealth and social class which produced clear evidence of higher levels of mortality in poorer areas. The 1851 report of health also contained a rough and ready examination of the occupations of those whose death had been recorded in the period 1841-1851. 1 The figures compiled by Wilde have all the problems associated with these early efforts at analysis of the health and mortality of a society. They relied upon the householder’s memory of recent deaths and their identification of disease. This was compounded in the case of phthisis by the tendency to include a variety of bronchial and ‘ wasting’ diseases within the general category of ‘consumption’. Fears that consumption was hereditary sometimes led to the deliberate concealment of the disease. Even the medically qualified could sometimes misdiagnose pulmonary tuberculosis as bronchitis or pleurisy, a problem which Linda Bryder argues was not totally eradicated in the twentieth century. 2

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Apart from establishing that pulmonary tuberculosis was endemic in Ireland and accounted for more deaths than fever, the mortality figures for consumption in Wilde’ s pioneering surveys have to be treated with caution. T o summarise, however , Wilde claimed ‘ The deaths for consumption returned on the Census forms for 1841 bore the proportion of 1 in every 8.7 of the total deaths from all causes; these returns for 1851 were in the proportion of 1 in every 8.8. and those for 1861 were as 1 in every 6.3.’3 Using Wilde’s figures R. C. Geary, chief statistician for the Free State government in the 1930s and 1940s, estimated that the 1840 tuberculosis death rate to have been 199 per 100,000 of the population, the 1850 , 293 and the 1860, 187. 4 A registry office was set up under an act of 1863 and responsibility for health and mortality statistics passed to the Registrar General of Ireland, the census of 1871 being the last one to contain a chapter on health and mortality. 5 Thereafter, information on the health of the Irish people was contained in the annual reports and decennial summaries of the Registrar General. Between 1871 and 1891 information was summarised by poor law union, whereas previously, and again after 1891, it was collated by the counties and provinces of Ireland. Wilde’s fame as Ireland’s pioneer medical investigator has tended to eclipse the contribution of those who followed after him. Nonetheless, Ireland continued to produce significant figures in this area. In 1879 Thomas Wrigley Grimshaw (1839-1900 ) was appointed to the office of registrar general, a post he held until 1900. Grimshaw superintended the censuses of 1881, 1891 both of which drew attention to the problem of tuberculosis. Grimshaw died suddenly during the preparation of the 1901 census to be succeeded by Robert G. Matheson who completed it. 6 Grimshaw was born in Whitehouse, County Antrim, the grandson of a prosperous calico printer and son of a dental surgeon. He was medically qualified – this was not always true of England’s registrar generals during this period – holding, during his tenure, posts as consulting physician to Steeven’s Hospital and Cork Street Fever Hospital. Grimshaw obtained a Diploma in State Medicine in 1873 and became a dominant figure in the public health movement in Ireland, president of the Dublin Sanitary Association 1885-8 and the Statistical and Social Enquiry Society of Ireland 1888-90. 7 Charles Cameron (1830-1921) also took up Wilde’s mantle during the half century or so that he headed Dublin’s public health department. He was appointed public analyst in 1862 and subsequently became executive and superintendent medical officer of health. Cameron was 30

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I made Professor of Hygiene and P olitical Medicine at the College of Surgeons in 1867. He was educated in Germany acquiring a medical degree and doctorate in chemistry there in 1856. 8 Cameron spoke and read German and it was he who in the Dublin Journal of Medical Science in 1882, first noted and pondered the implications of Koch’s discovery conveyed in the Berliner Klinische Wochenschrift of the 10 April 1882. 9 Ireland’s public health officials were aware that deaths from tuberculosis exceeded those classified as zymotic and infectious diseases (fevers) long before registration came into force in 1864. The census in Ireland in 1841 calculated that, in the preceding ten years, 153,098 people had died of consumption compared to 23,518 from fever. 10 The true extent of the problem and the fact that mortality was increasing only gradually came to light, however, as the medical statisticians began to acquire confidence in the process of collection of information. The Act of 1863, which created Ireland’s Registry General, had drawbacks and only in 1880, after the 1879 Birth and Registration Act was passed, were the procedures for registration tightened up. 11 Charles Cameron pointed out in 1892 that, before 1879, returns on burials, for which the burial officer was paid a fee, were consistently higher than registrations of death. ‘It was found in Dublin that the returns of burials exceeded by ten percent the registered deaths, from which it follows that, previous to 1879, a large number of deaths were not registered, and the published death rate was ten percent below the true rate.’12 He also referred to the fact that mortality rates depended upon a true estimate of the population of a town and district but estimates of the population often changed retrospectively between censuses. This meant that the data had to be periodically corrected, and conclusions based on earlier population estimates were sometimes subsequently found to be unsound. When, for example, corrected figures for Belfast’s population were published in the 1891 census showing an increase, Cameron commented, ‘A comparison in 1890 of the death rate of Belfast and Liverpool would have been unjustly to the disadvantage of the former.’13 Even after registration procedures were set in place there were still problems. Grimshaw summed up the problems of collecting reliable figures on consumption in 1887 though he remained convinced it was, by then, possible:

In using mortality statistics as a guide to the distribution of disease, we meet with the following difficulties. Some of the deaths are not registered. This however is not a matter of much consequence, as the total number of unregistered deaths is small. In a considerable number of cases the causes of death are not medically certified. This source of

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error is of comparatively small weight in the inquiry into phthisis, as the term consumption has (perhaps more than any other) a most distinct significance to the popular mind. Some causes of death are badly certified. I think phthisis is a disease where even this also is likely to be of comparatively slight importance. I do not, of course, look for scientific accuracy, but what is generally known as consumption, both within and without the profession, is a pretty well defined disease or group of diseases – in fact, I suppose we may consider that under it are included all those afflictions to which the phrase “suppurative destruction of the lungs” might be considered applicable. 14 There were other sources of information on health which complemented the reports of the registrar general. Workhouses and insane asylums returned figures for deaths. Sanitary Inspectors, medical officers of health and certifying surgeons wrote individual reports on mortality for their districts, often for conferences of their professional bodies or in pamphlets directed at arousing public support for health reform. From the mid-nineteenth century , the Dublin Quarterly Journal of Medical Science printed summaries of annual reports from sanitary officials particularly for Dublin and Belfast and, together with the Journal of the Statistical and Social Inquiry Society of Ireland and The Irish Builder it became an outlet for analyses of the health and medical condition of the Irish people. 15 Parliamentary investigations into the social condition of Ireland also included evidence submitted by the more active and vigorous public health officials including statistical analyses. Nonetheless, the figures for tuberculosis in the nineteenth century have to be regarded as broad generalisations, indicative, at most, of a trend but unlikely to be exact. Arguments based upon fine distinctions between sets of figures or upon differences inferred from relatively small changes, unsupported by other evidence, have to be discounted. Y et the statistical profile of tuberculosis in nineteenth century Ireland gives a relatively accurate picture of the medical etiology of tuberculosis as it is understood today and there is a degree of consistency between its main features and TB figures collected elsewhere in the British Isles and even further afield. They reveal a relatively long epidemic curve for tuberculosis with a natural tendency, as resistance among a population builds up, for mortality to fall over time. The highest mortality is recorded among young adults. Y oung adolescent girls have a higher rate than adolescent boys but at later ages the discrepancy narrows. Women in rural areas generally suffer from tuberculosis more frequently than

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Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I men. The incidence of tuberculosis is higher in towns than in the country, a difference which cannot be attributed solely to better reporting of deaths in the city. Urbanisation narrows the gap between male and female mortality rates from tuberculosis and causes the male rate, with some important exceptions, to rise above the female. Certain occupations are generally reported as having an above average susceptibility to tuberculosis of the lungs. 16 The poorer social classes suffer preponderantly more from tuberculosis than the better off. In other words the statistical picture of tuberculosis in the late- nineteenth century across Ireland, England ,Wales and Scotland and other societies is broadly similar as far as these variables are concerned, although, of course, what interests the historians is the differences that emerge. The historical picture of the tuberculosis epidemic is, however, complicated by the preconceptions of those who collected information about disease and mortality. They tended to concentrate upon fevers and what were called the zymotic diseases of typhoid, typhus, cholera and smallpox. There were various reasons for this. Cholera, typhoid and typhus epidemics were often short lived but caused a sudden and terrifying rise in mortality during their visitation. Outbreaks were accompanied by other indices of social distress such as economic depression, famine and migration which put stress upon the social and political fabric of a country. They loomed large in the public imagination as a threat to social order and stability. In some measure, they were considered to be preventable diseases and the state of public health and general well being of the community was measured by the degree to which mortality from these diseases had fallen. In contrast, the progress and spread of tuberculosis was slower and less dramatic and, until the late-nineteenth century, it was classified by the registrar general as a constitutional not zymotic or infectious disease. 17 Even when the extent of the toll taken upon life by tuberculosis and its infectious nature emerged at the end of the nineteenth century and mortality from cholera and typhus had fallen dramatically, public health officials were still geared up to achieving victory over their more familiar enemies. Gradually, however, attention begin to focus upon tuberculosis. In 1861 Wilde produced a brief analysis of the influence of the ‘sea board’ upon the incidence of tuberculosis in Ireland and, in the 1880s, Grimshaw took up this investigation. He conducted a series of climatic and geographical analyses of consumption in Ireland covering the relationship between the disease and mean 33

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones temperatures, elevation and annual rainfall. The discovery by Koch in 1882 of the tuberculosis bacillus and therefore of the infectious nature of tuberculosis did not make any immediate impact upon Grimshaw’s investigations. Only in the 1890s did he fully accept that tuberculosis was infectious and abandon the attempt to correlate mortality from consumption with geography and climate. However, Grimshaw’s work on the decennial tables for 1870–81 clarified, albeit inadvertently, the epidemiology of tuberculosis in Ireland. The geographical distribution Grimshaw revealed in 1885 illustrated that phthisis was more prevalent in towns than in the country and in the east than the west of Ireland. 18 In spite of this Grimshaw still clung to the notion that, apart from the fact that ‘higher civilisation favours the prevalence of phthisis’ , the reason for the difference in its incidence was climatic. 19 To test this hypothesis further, Grimshaw in the 1891 decennial report used the figures for 1871-80 and divided poor law unions by size and by proximity to the coast to test the hypothesis that the rate of mortality from tuberculosis was lower in bracing sea climates. Grimshaw found no evidence to support this. His conclusion was now unambiguous; tuberculosis in Ireland was highest in urban areas and ‘the conditions of life in towns tend to promote diseases of the chest’. He also commented, ‘ It is also a noteworthy fact ... that country districts surroundin g large towns and even at some considerable distance from urban centres show a higher death rate from Phthisis than those rural districts remote from large towns.’ This he considered ‘is probably owing to the spread of the disease by infection from the large towns, and also by persons from towns going into the country to die among their friends’. 20 By the 1890s Grimshaw accepted tuberculosis was most prevalent in urban areas regardless of their climate. 21 His doubts about the contagious nature of tuberculosis had also been put aside. In Grimshaw’s view this meant that tuberculosis had been brought within the realm of preventable disease, ‘the one above all others to be dealt with by sanitarians’. 22 Finally and most seriously , Grimshaw discovered that the incidence of tuberculosis in Ireland was rising. This was all the more shocking to him and his contemporaries because it was well known that mortality from tuberculosis was in decline in England, Wales and Scotland. Statistics compiled in Ireland in the 1880s showed that, beginning from a position in the 1860s and 1870s when her deaths from tuberculosis were lower than the rest of the United Kingdom, they had risen in the 1880s to the point at which they 34

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I exceeded those of England and Wales and were on a par with Scotland. This rise continued in the decennial decade 1890-1900 making Ireland, out of all the countries of the British Isles, the one with the highest rate of mortality from tuberculosis. Estimates of the extent of the epidemic in Ireland made at the time and by modern historians differ, but they all confirm a rise in mortality from TB during this period. 23 There was higher general mortality in Ireland. This can, in part, be attributed to the age structure of her population which, because of emigration, was older than elsewhere in the British Isles, However, this was not the cause of her higher mortality from tuberculosis. Examined by age, tuberculosis in Ireland took proportionately more of the young adult population aged between 15 and 34 years than in England and Wales during the period 1880-1900. 24 Tuberculosis accounted for 45.6 percent of all deaths in that age range in the period 1881-90. 25 Only in the decade 1901-11 did Irish rates of mortality from tuberculosis begin to decline and even then her rates remained higher than those of other parts of the British Isles throughout most of the twentieth century.In 1904, the highest year for tuberculosis deaths, tuberculosis accounted for almost 16 percent of all deaths in Ireland, a total of 12,694 of which 9,833 (around 12 percent of all deaths) were from pulmonary tuberculosis. 26 Contemporaries referred in this period to an annual toll of around ten thousand deaths from tuberculosis and to a greater number, possibly a further sixty to eighty thousand, who were suffering from the disease.

• A debate about the reason for the rise in Ireland’ s mortality from tuberculosis took place at the turn of the century in the great institutions of Irish medicine – the Dublin Quarterly Journal of Medical Science , the Royal Colleges and the Royal Academy of Medicine in Ireland – in government reports on tuberculosis and in the groups set up to combat the disease such as the Irish branches of the National Association for the Prevention of Consumption and Tuberculosis (NAPT) and the Women’s National Health Association (WNHA). No one overriding explanation emerged and, in fact, those concerned with tuberculosis tended to offer several possible causes. Some of these were only tangential to modern views of the causes of tuberculosis epidemics though others are still discussed among historians as possible influences upon tuberculosis mortality. Among the possible reasons put forward for Ireland’ s high 35

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones tuberculosis mortality was whether the Celt was particular ly susceptible to consumption. 27 The Irish medical profession were largely sceptical about this. Grimshaw’s figures on the distribution of phthisis had demonstrated that the mortality rate was lowest in the west of Ireland, the most Celticised region in Ireland. Sir John Byers, professor of midwifery at Queen’s College, Belfast, asked in 1907 why ‘according to the Registrar General’s return, Ireland in 1864, when there were far more Celts in the country, had a lower death rate from tuberculosis than either England or Scotland?’ He also pointed to the fact that, aside from Belfast and Dublin, ‘of the small urban towns in Ireland, the one with the highest phthisis death rate is Newtownards, situated in the most Scottish country in Ireland – Down – where, at the time of the Ulster plantation the people came not from the highlands, the home of the Scotch Celts, but from the lowlands’. 28 Patterns of mortality within Ireland did not support theories of a particularly Celtic susceptibility but the argument kept reappearing in the twentieth century because of the greater incidence of the disease amongst Irish immigrants to the United States and Britain. 29 In 1933 F.C.S. Bradbury discussed the prevalence of tuberculosis among Irish immigrants on Tyneside and in 1952, in the context of the high emigration from Ireland taking place after the Second World War, so did Brice Clarke, chief tuberculosis officer for Northern Ireland.30 Both, in common with most Irish medical professionals, dismissed the view of Celtic susceptibility and took the view that high rates of tuberculosis could be explained by the fact that emigration took place from predominantly rural areas in Ireland where tuberculosis mortality was low and that this explained the susceptibility to the disease among Irish immigrants. F.C.S. Bradbury argued: ‘It is worthy of note that the majority of Irish families met within those areas studied originated in the west of Ireland chiefly in the counties of Galway and Sligo. The greater number of these came to Tyneside thirty to seventy years ago … It can easily be imagined that the change from a comparatively isolated existence in the country to the overcrowded conditio ns of tenemented towns would readily favour the occurrence of tuberculosis in susceptible individuals.’31 Brice Clarke too dismissed the notion. ‘There is no single ethnic type identified with the Celtic race which is essentially a language and culture group. Late tuberculisation and other epidemio logical and environm ental conditions form a sufficient explanation for the high rates among the Breton, Welsh and Irish populations’. 32 36

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I

Bradbury and Brice Clarke’s belief that relative isolation rendered some groups more susceptible to tuberculosis– made them as far as TB was concerned ‘a virgin soil’ in which the disease easily took root – was discussed before 1914 in the context of growing tuberculosis mortality among colonial peoples in the Empire. 33 The credibility of the theory was given a boost by a sudden rise in the tuberculosis mortality of African troops posted to France 1914-18, by evidence of very high rates among native Americans after the colonisation of the United States and rural blacks migrating to urban areas in the United States in the twentieth century, and the high mortality of black urban migrants in South Africa. 34 But the virgin soil theory could also be applied to various geographically isolated communities within Europe in, for example, the Scottish Highlands, or parts of Scandinavia. In the inter war years, the childhood tuberculosis specialist Dorothy Stopford Price used the concept to explain the high incidence of TB among emigrants from rural Ireland. 35 The ‘virgin soil’ theory can lead to confusion. A virgin soil is not necessarily a racial group – though it might be – but a social and geographical entity . 36 The habit of thinking in terms of racial biological distinctiveness persisted among some proponents of ‘virgin soil’ theory, largely because of the intellectual context in which they worked in the first half of the twentieth century . However, all historical communities at some point in their existence are potentially a ‘virgin soil’, including the descendants of planters from lowland Scotland in the district of Newtownards to whose high tuberculosis rates Byers referred in 1907. The point at which a community is drawn into more frequent contact and integration with the outside world leading to a change in their immunological status, is the moment when they become visible as a ‘virgin soil’. A further problem arises because of the implication in the virgin soil theory that high tuberculosis mortality is caused when groups, among whom the disease is rare or unknown, suddenly encounter TB. There is no suggestion, however, that tuberculosis was not endemic in rural Ireland and Randall Packard argues there is evidence that it existed in rural Africa before colonisation. So what has to be explained is not just the appearance of tuberculosis among these groups – for it may already be there – but the sudden rise in mortality from the disease. Susceptibility might play a part but it is likely that the triggering factors are also social. R. S. Doig in his study of the the TB epidemic in the Scottish island of Lewis which peaked in 1924, attributed the sudden rise in mortality to the increased integration of the island economy with the 37

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones outside world. This improved the island’s standard of living but also the incidence of TB. 37 However, he also points to the chronic overcrowding problem in Lewis as a factor which aided transmission of the disease. Similarly , Barbara Bates believes that the social conditions of newly arrived migrant blacks from the south in northern American cities exacerbated the problem of tuberculosis among them, and she also puts forward the hypothesis that, for European immigrants to the United States including the Irish, the actual experience of emigrant ships with the close contact and stress it involved, was a factor in their subsequent high TB rates. 38 Two factors were probably at work to raise the tuberculosis rate among the migrating rural Irish, one of which was the dangers of increased contact with the disease for those newly arrived in urban areas, a factor also affecting the incidence of tuberculosis mortality among the indigenous population moving to towns and cities in Ireland in the late-nineteenth century, and the stress and social difficulties of urban life. Thus it is possible that some of the TB experienced by Irish rural migrants was not due to a first time infection but the reactivation of an existing tuberculous infection exacerbated by the problems of urban living for the newly arrived immigrant. At the height of the tuberculosis epidemic in Ireland, there was little knowledge or understanding about susceptibility and resistance and their role in the epidemiology of tuberculosis. Emigration itself however was prominent in the debate on Irish mortality from tuberculosis. Several distinguished medical men attributed the incidence of tuberculosis in Ireland to differential emigration of the healthiest and most fit specimens of the race. In 1909 Sir William Osler wrote to the Countess of Aberdeen, wife of Ireland’s viceroy and founder of the Women’s National Health Association, that

Dr McWalter is right in his contention that one important cause for the increase of tuberculosis in Ireland is the incessant drain of emigration. Only a few months ago I stood beside the ship’s doctor at the gangway of the Majestic and saw some three hundred young Irish men and women come aboard – everyone healthy and vigorous.39 The impact of emigration was also perceived in another way. In the opinion of many, Ireland’s figures for tuberculosis mortality were inflated by receiving back into Ireland seriously ill emigrants who came home to die. One doctor in 1907 claimed tuberculosis was referred to in the west of Ireland as ‘the English cold’ because it was 38

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I associated with the return of those who spent part of the year in Britain doing seasonal agricultural labour. 40 One tuberculosis officer complained in 1912, ‘I am attending five cases of pulmonary TB, four of which have returned from the USA.’41 In response to these fears, Henry Robinson, the head of the Local Government Board (Ireland), sought, unsuccessfully, to get the United States immigration service in the First World War to medically examine returnees before they set foot back in Ireland. 42 Returnees did in fact inflate the figures. In the 1950s at the height of Irish emigration to Britain it was calculated that some ten percent of patients in Irish tuberculosis institutions were returnees. 43 However, the epidemic could not be laid at their door. The mortality rate for tuberculosis was as high among the inhabitants of Dublin and Belfast as it was among the Irish in London or New York. 44 Ireland had a lower rate of returnees among her emigrants than other nations.45 The impact of the returnees on overall mortality figures must have been relatively small and has to be balanced against the fact that emigration was among the age ranges with the highest tuberculosis mortality rates. The interpretation of the impact of emigration varied widely and was often contradictory. Emigration could simultaneously be seen as increasing the rate among those left behind by removing the healthiest from Ireland (Osler); increasing the risk for the immigrant of contracting the disease because they moved from areas of low incidence to areas where contact with the disease was more likely (Bradbury); and artificially inflating the rate in Ireland by providing a final refuge for those who had contracted the disease elsewhere (Robinson).

• Was Ireland’ s increasing mortality from tuberculosis due to her poverty? Relative to England and Scotland, Ireland was poor. However, the problem with arguments based upon Ireland’s poverty was that Ireland in 1890 was significantly more prosperous than it had been either in 1850 or in 1880 when mortality from tuberculosis was lower. Arthur Newsholme, the chief medical officer for England and Wales, listed the indices of this prosperity in his discussion of Ireland’s tuberculosis mortality in 1907. The proportion of class 4 housing in Ireland (one roomed cabins) had fallen dramatically from 37 percent in 1841 to 1.1 percent in 1901. The wages of agricultural labourers, though lower than elsewhere in the United Kingdom, had risen by around 42 percent. The proportion of incomes eligible for taxation 39

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones had grown as had the amount deposited in savings accounts. 46 Ireland had an increasing demand for consumables and this was reflected in the growth of indigenous businesses. Literacy and school attendance increased in this period as did the demand for third level education. 47 Ireland was still poorer than Britain but not noticeably poorer than many other European nations. 48 Medical men and women saw this greater wealth reflected in the growth of medical graduates and in the market for their services. Of course it all hinged on the notion of what constituted poverty and how it contributed to disease. Irish poverty was often seen in the nineteenth century as a problem of the congested rural districts of the west. That is why Grimshaw in his discussions of tuberculosis in 1885 dismissed poverty as the cause of high mortality from phthisis. In 1879-81, when he was computing statistics for the 1881 decennial report, the newspapers had been full of the impending crisis in the west brought about by falling agricultural prices. In contrast Irish towns and cities, with their high rates of consumptive deaths, appeared relatively prosperous. The question of poverty and mortality, however, involves social class as well as region and economic sector. Statistical evidence of higher rates of mortality among the poor in the nineteenth century existed, but statistics tended to be collected by district and occupation rather than by broad social classifications. In England and Wales a social class classification of the population which could be related to disease and mortality was only available for the 1911 census, although the need for one was felt earlier. The slowness of this to develop was partly because the definition of social class was, in itself, fraught with difficult economic, ideological and political questions.49 There were similar problems in the development of a scientific measure of what constituted poverty. 50 Even in the absence of a generally agreed statistical or scientific framework, it was clear that there were areas in the nineteenth century city where poor people lived and in which mortality was high. There were visible evidences of poverty in them, in the condition of housing and sanitation in particular. Most public health officials were convinced that this severely aggravated the problem of disease. 51 These areas suffered particularly badly during epidemic outbreaks of fever and they attracted particular attention from the nineteenth century public health movement as sources of dirt and miasmic fogs and the contagions they were reputed to bring with them. Even then there was no general agreement about the exact relationship between poverty and the ill health prevalent in these 40

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I areas. The fact that the poor appeared to suffer more from contagious diseases illustrated for some the debilitating effects of cold and hunger and suggested that ill health could be combated by alleviating poverty. For others, the deteriorating environment in poor areas was the primary cause of the problem and, though sometimes this could be attributed to poverty, it was often, in their view, the result of poor ‘domestic management’ and ignorance among the working-class. In that case the situation could be improved not by alleviating poverty but by environmental improvement and instruction in hygiene. 52 Statistics of mortality were computed by occupational group for Dublin in the 1860s but these bore only a very rough and ready approximation to social class. However Grimshaw from 1884, on the suggestion of the Dublin Sanitary Association, produced regular social class analyses of mortality for Dublin which anticipated the social classification in the 1911 census for England and Wales. 53 He grouped the population of Dublin into five main classes: (1) professional and independent, (2) middle-class, (3) artisan and petty shopkeepers, (4) general service-class and (5) inmates of workhouses. 54 These were assigned to the groups by the status of their occupation or, where there was no occupation recorded, by access to private and independent means. In the case of women and children with no recorded occupation, they were categorised by the social status of the head of the household or by the district in which they resided. This social class breakdown of m ortality from the main zymotic and constitutional diseases conduct ed for Dublin from the 1880s to 1911 is, however, marred by a nu mber of complexities and ambiguities. Grimshaw himself admitted that the fact that the general mortality figure for the artisan and petty shopkeeper class was lower than that for the middle-class had provoked general surprise and led to unfavourable comment on his statistics. He attributed the result to the problem that ‘the age composition of the classes varies considerably, the other that there are m any indefinite descriptions such as “ gentleman’s wife, daughter, w idow” or “ lady.”’55 Other problems were that Grimshaw assigned to class 3 ‘Other trades and callings ranking with trades’ com prising around 22 percent of the total number in that class but about whose occupational character we cannot be sure. ‘Food supply trades’ placed in class 3 included a potentially wide variety of occupations. In class 2 a considerable number of occupations – 19 percent of the total – are not assigned to any occupational group at all but put dow n as ‘ miscellaneous including all householders in second-class localities’. 41

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Grimshaw’s calculations can only provide a broad picture and they were not conducted to specifically assess the tuberculosis situation. However, they do provide some guide to the rate of phthisis in Dublin broken down by social class. With the exception of class 5 workhouse inmates who have the highest pulmonary tuberculosis mortality of any group for the whole of the period 1885- 1911, it is class 3, artisans and petty shopkeepers, who, from 1885- 1900, emerge as the group with the highest phthisis mortality. 56 This is because of a very high phthisis rate among an occupational group in this class –category 8 consisting of working engineers, watchmakers, printers, engravers and jewellers. This encompasses those working in ‘the dusty trades’ traditionally associated with high levels of consumption. Until 1901-11 this occupational group had a higher phthisis mortality rate than any other. From 1901-11, however, class 4, the general service-class, emerges as having the highest tuberculosis mortality, in part because the rate for category 8 – working engineers, watchmakers, printers, engravers and jeweller – in class 3 falls. The other significant reason is the continuing high rates among two occupational categories within class 4 itself. From 1885-98 category 16 (coach and car drivers, vanmen) and class 17 (hawkers, porters and labourers) had the next highest mortality from phthisis to category 8 – working engineers, watchmakers, printers, engravers and jewellers – and from 1901-11 the highest rate of all occupational categories. The high figures for deaths from phthisis for Dublin’s working engineers, jewellers and engravers are not unexpected and are reflected in other nineteenth century studies of the occupational incidence of tuberculosis. 57 The high toll of tuberculosis upon occupational categories who can be graded as unskilled or semi skilled and among the lower paid and more economically marginal urban dweller is also typical. In Dublin this association appears to grow stronger towards the end of the century. Unfortunately no comparable social class tables were done for Belfast and other Irish cities but other studies of mortality in Belfast, discussed in the next chapter, also bring to light a connection between occupation, poverty and tuberculosis. 58

• Irish medical men and women were beneficiaries of the economic improvement that had taken place at the end of the nineteenth century and the argument that poverty was the cause of high tuberculosis rates was not widely held among them. They did, 42

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I however, begin to conceptualise the tuberculosis epidemic in terms of relative disadvantage within the cities. Once tuberculosis was discovered to be an infectious disease, it concentrated minds upon the state of hygiene of the urban areas and this, in itself, put the focus upon the sanitary condition of the poor. The sanitary state of the towns and cities dominated the campaign against zymotic disease throughout the nineteenth century. It led to the creation of an infrastructure of agencies to bring mortality from these diseases down particularly in the poorer areas. Therefore the question arose of whether it was the failure of Ireland’s public health services which contributed to, even if it did not initially cause, her high death rate from tuberculosis. In a series of articles between 1902-7, Arthur Newsholme discussed the role played by the public authorities in the decline in tuberculosis mortality rate in Britain. 59 There was, of course, no public health legislation or campaign specifically directed against tuberculosis until the 1890s but Newsholme identified a measure which he felt had, inadvertently , contributed towards the falling mortality from tuberculosis. It was, he argued, the increasing institutionalization of the poor, including the sick poor, in the workhouse and workhouse infirmary in Britain which had, by segregating the tuberculous from their families and society at large, assisted the decline in the tuberculosis death rate. To illustrate this Newsholme used figures, derived primarily from Brighton, where he was medical officer of health 1888-1908, to show how mortality from tuberculosis had fallen in line with the rise in the proportion of paupers given poor relief inside the workhouse. Newsholme used Ireland to argue that improvements in social and economic conditions in the late-nineteenth century were not, in themselves, sufficient to lower the tuberculosis death rate. He likened poverty to dry tinder which the flame of infectious disease set alight. If there was a great deal of tinder about the danger of a serious fire was greater. However, ultimately , an efficient public health system could ensure public safety even under unfavourable economic and social conditions. Newsholme paid tribute to Ireland’ s public health system in reducing the mortality rate from the zymotic diseases of cholera, typhus and small pox. Public health legislation in Ireland permitted the notification and isolation of people suffering from these conditions. But, Newsholme argued that, since 1851 she had also a system of medical dispensaries supported by the poor law, which relieved the sick poor in their own homes. Ireland, he argued, ‘has 43

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones settled down to a vast system of home relief of the sick’. 60 This meant that she was a negative illustration of Newsholme’s thesis; she had low levels of institutionalization of the poor and sick poor and a high level of tuberculo sis mortalit y. In Leonard Wilson’ s words, ‘Newsholme found the answer to the Irish paradox in the policy of giving relief to the Irish poor in their own homes rather than in workhouses.’ 61 Newsholme’s arguments in relation to Ireland are unsustainable. The dispensary system which gave outdoor medical relief, measured by the number of tickets issued, was certainly used much more in 1914 than in 1852 when the dispensaries first came under the Irish Poor Law. During that period the numbers in workhouses also dropped. However, the population overall fell during this period and, in fact, the numbers in workhouses, including the workhouse infirmaries, per 1000 of the population increased slightly between 1870 and 1900. 62 More importantly, it was greater per 1000 of the population than in England and Wales. Even in the peak year for indoor relief in England and Wales, 1910, Ireland still had a higher proportion of her population in the workhouse. 63 If we add to the workhouse population the numbers in the county asylums which also increased in the late-nineteenth century, 64 Ireland was a more, rather than less, institutionalised nation than England and Wales – a fact confirmed in Newsholme’s own calculations. 65 Newsholme was convinced that segregation would make a significant contribution to tackling the problem of tuberculosis but his arguments should be seen as special pleading for a system of public sanatoria where the tuberculous poor could be isolated from the healthy population. His views on the causes of Ireland’s epidemic had little resonance among the Irish medical profession even though the majority were committed, as he was, to a policy of segregation of the tuberculous. In fact, Newsholme modified the argument in later articles arguing that it was not the extent of segregation in the workhouse that affected Ireland’s tuberculosis rate but the length of stay . He produced a series of calculations to show the average stay in the North and South Dublin workhouse infirmaries of phthisis patients was 53 days in 1904-5 compared with 175 in Brighton, 1897-1905 and 311 in Sheffield. 66 Therefore, it was the efficacy of segregation, measured by the length of time spent in the workhouse, rather than its extent which differed in Ireland. Newsholme’s point was probably true for urban workhouses in Ireland where pressure upon accommodation was greatest. 67 But, 44

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I given the slow pace at which pulmonary tuberculosis developed in many sufferers, it is unlikely that a difference in the length of stay, unless of great magnitude, would appreciably alter the spread of the disease so long as a sufferer was returned to the community at some point in the course of their disease In fact, the Irish workhouse, at least before consciousness developed of the need to segregate the tuberculous from other inmates, probably aggravated the problem. Deaths from tuberculosis in Irish workhouses and in county asylums were high and, although tuberculosis was often a cause of the poor gravitating to the workhouse, not all in the workhouse were tuberculous. There is a chance that overcrowded conditions there spread infection to those not infected. 68 It is at least possible, as Bryder argues in her comments on Wilson, that a high level of workhouse institutionalization exacerbated the problem of tuberculosis in the community, especially when combined with a greater volume of discharges. 69 Wilson argues the decline in tuberculosis in Ireland can be located at the moment when sanatoria began to be built though he admits they were ‘few and inadequate’. 70 This argument also cannot be sustained. In 1905, when mortality from tuberculosis began to fall, there was only one purpose built sanatorium in Ireland which reserved a proportion of beds for public patients, Newcastle Hospital, County Wicklow. This opened in 1896 with 24 beds and, by 1905, bed provision had risen to around 100. The second, Whiteabbey Tuberculosis Hospital, opened in 1906 to cater for the tuberculous among Belfast’ s workhouse population. However, pulmonar y tuberculosis in Belfast had already begun to decline from the 1890s. 71 Newsholme exempted other parts of the Irish public health services and the poor law from criticism. In terms of provision of public and voluntary hospitals, opinion in Ireland was that the Irish poor were relatively well off although rural areas were often lacking in medical amenities compared to the towns and cities. The dispensary system was cited as a significant benefit to the Irish population at large, not just to the pauper class, and other forms of medical provision for the sick poor were also considered to be relatively advanced. 72 Although public health legislation tended to track that of England and Wales, it was in place and, particularly in urban areas, the sanitary inspectorate and medical officers of health formed a cadre of professional and often dedicated individuals. There was, however, a constant strain of criticism about the state of public health, particularly in Irish towns. Edward Dillon Mapother (1835-1908), physician to St Vincent’s Hospital, held the 45

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones chair in public hygiene at the Royal College of Physicians in Ireland from 1867.73 In 1866 Mapother argued, ‘Thus while we have for our poor the best organised system of curative medicine in the world we cannot be said to have arrangements for prevention.’74 Public health and sanitary officers often tried to force the pace of improvement by exaggerating problems. Mapother, who was engaged in campaigning for public health legislation for Dublin at the time, might have been expected to put the case as strongly as he could. Nonetheless, although mortality from epidemic disease began to fall in Ireland in the late-nineteenth century, for most of that time the two main cities in Ireland – Belfast and Dublin – suffered higher general mortality rates than many British cities. 75 This was particular true for Dublin. 76 Zymotic disease was a sensitive indicator of the efficiency of public health systems and, judged by this, there were still substantial problems with the infrastructure of public health in Dublin. In 1897, the figures for deaths from scarlet fever and measles in Dublin rose sharply and a special committee was set up to inquire into the epidemic which showed that falls in mortality from zymotic disease had not been sustained during that decade. 77 The question of how efficiently the public health system operated in nineteenth century Ireland still awaits a full scale history. 78 However, it was not a negligible force and its representatives like Mapother, Cameron and Grimshaw were important public figures. At the same time, it could be argued that the culture of civic improvement was handicapped in various ways in Ireland. Reform of the local government franchise, which Simon Szreter sees as giving rise to a proactive public health movement in cities like Birmingham created out of an alliance between the professional classes, larger business men and the working- class electorate, was more difficult to establish in Ireland. Divisions between nationalism and unionism limited the possibility of similar alliances. Though there was a growing working-class electorate in Ireland, Irish democracy was still dominated by the property owner – the middle ranking businessmen, shop keeper and farmer – who was hostile to increased expenditure at local level. Even when public health legislation existed, it was often difficult to enforce and enthusiasm for public health reform was low , hampered by parsimony among rate payers.79 Mary Daly comments, in relation to nineteenth century Dublin, that ‘ With the exception of some members of the Dublin Sanitary Association whose interest soon waned, nobody approached the city’s health with any type of crusading zeal.’80 A generally higher level of disease in the city and poorer sanitary infrastructure might not have contributed directly to raising the phthisis rate – except in certain 46

Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access The Tuberculosis Epidemic in Ireland: I areas such as housing – but it might have contributed indirectly by both increasing general debility among the poorer population and by making hygienic measures, which might have reduced the chances of infection, more difficult to enforce. Thus, as Anne Hardy has pointed out, mortality from tuberculosis might very well have been lowered by more general sanitary improvement covering the workplace as well as the home without necessarily being undertaken with tuberculosis in mind. 81 The public health campaign against tuberculosis in Ireland only officially got underway in 1899 with the foundation of the National Association for the Prevention of T uberculosis in Dublin. Consciousness of the importance of a healthy urban environment, however, preceded it. Several decades before Koch’s discovery, manuals on public health administration in Ireland instructed medical officers of health to combat phthisis by the encouragement of cleanliness, ventilation and reduction of overcrowding in public institutions. 82 Arthur Wynne Foote, physician to the Meath, set out in Lectures to the Royal College of Physicians in Ireland in 1877 the outlines of a public health approach to tuberculosis:

There can be little doubt that the cultivation of a healthy public opinion on the vital importance of the proper construction of houses; correct principles of ventilation, heating and drainage; of the dangers of overcrowding; the daily duration of labour; the advantage of cleanliness; the supervision of food; and the prevention of intemperance, will, by gradually securing an improvement of shelter, air, food and drink, comfort and cleanliness, and rest of the poorer classes, tend by degrees to effect their moral and physical amelioration and thereby eliminate or abate the causes of scrofula to such a degree as to strike a dreaded blow at the very roots of tuberculosis. 83 Although consciousness of the need to combat phthisis was developing among Ireland’s public health officials well before Koch’s discovery in 1882, the problems they faced were formidable. Public health reform had some success in bringing down mortality from epidemic disease but Irish towns were still among the most unhealthy in the British Isles. The largest difference in mortality rates between the main Irish and British cities at the end of the nineteenth century was for phthisis and whilst environmental improvement in Britain at the end of the nineteenth century took place during a decline in the incidence of tuberculosis mortality, in Ireland public health officials were struggling against an epidemic that in 1899 was still to reach its peak. 47

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Appendix 1

Mortality from Tuberculosis in Ireland per 100,000 persons

DecadeAverage Annual RateOther Total (Phthisis) (all forms TB)

1871–80 195 18 260 1881–90 209 17 267 1891–1900 213 22 277 1901–10 202 32 263

Source: Decennial Report of the Registrar General 1901-1910, xxxi

Mean Annual Death Rate per 100,000 Living (Respiratory TB only) IrelandEngland and Wales Scotland

1871 189 232 261 1881 204 189 217 1891 213 156 178 1901 216 128 155 1920 202

Source: Ruth Barrington, Health Medicine and Politics in Ireland , Dublin, Institute of Public Administration, 1987, 6. Table 3.

Mortality from Pulmonary TB in Ireland 1865 165 1870 167 1880 190 1890 200 1900 218 1910 171

Source:T uberculosis in Ireland Report of the National Tuberculosis Survey (1950-3) . Medical Research Council of Ireland, Dublin, 1954, 21. Table 2. 48

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Appendix 2

Age Specific Mortality from TB (all forms) per 100,000 Living Persons

Age RangeEngland & ScotlandIreland Wales 1871–80 15-34 306 403 349 35+ 234 209 185

1881–90 15-34 266 345 394 35+ 208 173 169

1891–1900 15-34 188 284 399 35+ 180 164 161

Source: A Barr (op. cit.). Calculated from Tables 11-11B, pp. 58–67 and pp. 62–3.

Appendix 3

Number of Deaths from TB as a Proportion of Total Deaths

No. of DeathsTB Deaths% TB to Deaths% Phthisis Only Pulmonary ( )

1864 93,144 – – – 1874 91,961 12,565 (9,416) 13.66 10.23 1884 87,154 13,462 (10,583) 15.4 12.14 1894 83,528 12,143 (9,626) 14.5 16.5 1904 79,513 12,694 (9,833) 15.96 12.3 1914 71,345 9,089 (–) 12.7

Source:Reports of the Registrar General (Ireland)

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Appendix 4

Mortality from phthisis per 100,000 persons by Social Class in Dublin.

1885 1898 1901–10

IProfessional and Independent Class 79.6 115.5 102

IIMiddle Class 334.7 223.3 170

IIIArtisan and Petty Shopkeepers 343.8 314.9 249

IVGeneral Service Class 308.8 270.3 254.9

VInmates of Workhouses 394 450 532

Source: Public Health Reports for Dublin.

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Appendix 5

Mortality per 100,000 (phthisis only). Representing the four highest figures for mortality in each period together with the occupational category.

Occupational Category 1885 1898 1901-10

6. Clerks and Commercial Assistants (ranked as Class II middle-class) - 323.9 -

8.Working Engineers,Printers, Watchmakers,Jewellers, Engravers - 349.8 270 (Class III)

11. Food Supply Trades 367 - - (Class III)

12. Other Trades and Callings ranking with Trades 473 404.6 300 (Class III)

16. Coach and Car Drivers, Vanmen 432 333 280 (Class IV)

17. Hawkers,Porters, Labourers 394 341 300 (Class IV)

Source:Public Health Reports for Dublin

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Notes 1. Peter Froggatt, ‘Sir William Wilde and the 1851 Census of Ireland’ Medical History , vol. 9 (1965), 302–27. The first census in Ireland was 1813 but plagued with difficulties and largely unreliable. 2. Linda Bryder, ‘“Not Always One and the Same Thing”. The Registration of Tuberculosis Deaths in Britain 1900-1950’, Social History of Medicine vol. 9 number 2, (1996), 252–265. 3.Census of Ireland for the Year 1861 Part III Vital Statistics vol. 1 Report and Tables on the Status of Disease. (Dublin: Alex Thom.) PP 1863 vol 58 Cd 3204, 32. This showed an increase in the percentage of consumptive deaths to all deaths. As regards the consumptive sick Wilde calculated that 1 in 25 of all the sick were consumptive in 1851 compared to 1 in 29 in 1861. He called this ‘a pleasing decrease’. Ibid., 36. 4. Quoted in Tuberculosis in Ireland . (National Tuberculosis Survey, Medical Research Council of Ireland, 1954), 20. 5. A Registration Act for Ireland was passed in 1863. England and Wales had its registration process created in 1836 and Scotland in 1854. 6. Robert G. Matheson (1845-1926) was registrar general 1900-1909. He had been assistant registrar 1879-1900 and Commissioner of Irish Censuses 1881,1891, 1901. He in turn was succeeded by William Henry Thompson, registrar general from 1909-1918. 7. See the obituaries in the British Medical Journal, vol. 1. (1900), 289–290 and Dublin Journal of Medical Science vol. CIX (1900), 157–160. Grimshaw was also a strong supporter of the BMA 8. Obituary of Sir Charles Cameron, Irish Times 28 February 1921. 9. Dublin Journal of Medical Science, vol. 74 (1882), 498. In 1879 in his Public Health Report for the Half Year Cameron asked the question whether the long-held notion ‘entertained by both medical and non medical persons’ that phthisis was contagious was true. He cited Tappeiner’s experiments on dogs, repeated by Dr Max Schottelius, suggesting that inhalation of dried sputum from the phthisical produced tuberculosis but he went on ‘the whole subject under discussion may be regarded as unsettled’. Dublin Journal of Medical Science, vol. 67 ( 1879), 136–51: 143. Cameron read accounts of these experiments in Virchow’s Archiv for 1878. 10. Quoted in A. Barr, ‘A Short History of Tuberculosis in Ireland’, Irish Journal of Medical Science vol. 125 (1956), 58–67: 58. This represents a phthisis figure of 170 per 100,000 averaged for the decade 1831-41. Between 1861-70 it rose to 219 per 100,000.

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11. Under the 1863 Act registration of a death was not time limited. The Birth and Registration Act of 1879 required notice of a death within five days unless written notice and a medical certificate was furnished within fourteen days. All relatives were made informants which led to the drawback that the cause of death was often based on the opinion of the relatives. A penalty followed after the fourteen days elapsed but the legislation allowed a further twelve month period for registration. After that the Registrar General became the only official registrant. Even though the 1879 Act was an improvement over the 1863 Act, historians suspect that there still may have been problems of enforcement among poorer families in the remoter districts. 12. Charles Cameron, ‘The Victorian Era, the Age of Sanitation’, Presidential Address to the Congress of the Sanitary Institute: reprinted in Dublin Journal of Medical Science vol. XCIV, (1 October 1892), 298–313: 303. 13. Ibid., 304 14. T. W. Grimshaw, ‘On 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: 315–6. 15. For a history of the Statistical and Social Inquiry Society of Ireland see Mary E. Daly, The Spirit of Earnest Inquiry. The Statistical and Social Inquiry Society of Ireland 1847-1997 (Dublin: the Statistical and Social Inquiry Society of Ireland, 1997). 16. In 1836 Arthur Clarke in Essays on the Inhalation of Iodine in Tubercular Consumption (Dublin: A Thom), attributed high mortality from phthisis among shoemakers to their stooping posture and among hairdressers, stone workers, tailors and knife grinders to dust. In 1871 the Decennial Census contained an analysis of mortality in certain occupations for Dublin 1861-70. This showed the percentage of deaths attributed to phthisis among male occupations to be highest for tailors (35%) printers (34%), clerks (30%) and shopkeepers (29.5%). Among women the highest mortality from consumption was reported for dressmakers (40%) and servants (30%). Some of the other occupational samples are too small to be of much value. A proportion of the high phthisis mortality among certain dusty occupations was most likely due to other respiratory complaints, which, until the twentieth century, remained unidentified, mistaken for pulmonary TB. However there are certain rare forms of pulmonary TB which can be induced by the disintegration of materials in manufacturing i.e. dust. There are also other possible 53

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occupational hazards in certain dusty trades, such as confined workspaces, which may play a part in the transmission of pulmonary TB. For further discussion of these figures see Chapter 3 footnote 67. 17. T.W. Grimshaw in his discussion of the figures for 1871-1880 placed tuberculosis under the heading of constitutional diseases: ‘Not only do these diseases cause a great number of deaths (amounting in the decade to 137,558, or 14.2 percent of the total mortality of Ireland during the period) but they only prevail among what are termed “delicate people” or people with “delicate constitutions”’, Registrar General (Ireland) Decennial Summaries 1871-1910 , 32. 18. 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. The phthisis rate for civic unions, defined by Grimshaw as an area with a municipal government and a population of 10,000 and over, was 280 per 100,000 in the period 1871-80 and for rural areas it was 160 per 100,000. 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: 161. 19. Grimshaw, ‘On 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: 326. 20. Registrar General (Ireland) Decennial Summaries, Report for1891 , op. cit. (note 17), 36. 21. Because of Grimshaw’s work and Koch’s discovery, belief in the climatic causes of tuberculosis declined among medical men and women in Ireland. Nevertheless it was still sufficiently influential for Sir John Byers, professor of midwifery at Queen’s College, to attack the notion in 1907. He pointed out to the conference on tuberculosis convened in Dublin by Lady Aberdeen’s Women’s National Health Association that ‘We have been told the prevalence of tuberculosis in Ireland is due to its damp atmosphere, the general humidity causing chest affections [sic] which tend to form a nidus for the tubercule bacillus.’ He pointed out, however, that Glasgow had a higher rainfall but a lower phthisis rate than Belfast. ‘Why is TB so Common in Ireland?’ 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, 63–4. 54

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22. T. W. Grimshaw, ‘The Prevalence of Tuberculosis in Ireland and the Measures necessary for its Control’, op. cit. (note 18), 164. 23. See Appendix 1. 24. See Appendix 2. 25. Grimshaw, ‘The Prevalence of TB in Ireland’, op. cit. (note 18), 172. 26. See Appendix 3. 27. The idea owed something to the Irish literary revival of the time which opposed the practical, down to earth Saxon against the image of a highly strung, volatile, artistic and emotional Celt, resembling the ‘phthisical personality’ constructed in the nineteenth century. 28. Byers in Ishbel Gorden, Countess of Aberdeen (ed.), Ireland’s Crusade against Tuberculosis (Dublin: Maunsel and Co., vol. 1, 1908), 66. 29. For the USA see Robert E. Kennedy Jr., The Irish Emigration, Marriage and Fertility (Berkeley: University of California Press, 1973), 50 Table 8. See also F. B. Smith, The Retreat of Tuberculosis 1850-1950 (London: Croom Helm, 1988), 221 on the high incidence among Irish medical personnel in Britain. 30. F. C. S. Bradbury, ‘A Report of an Investigation into the Incidence of TB in Certain Tyneside Districts’, in Causal Factors in Tuberculosis (London: NAPT, 1933) and Brice R. Clarke, Causes and Prevention of Tuberculosis (Edinburgh & London:E. & S. Livingstone, 1952). 31. Bradbury, ibid., 61. 32. Quoted in Norman MacDonald and Evelyn V. Hess, ‘Pulmonary Tuberculosis in Irish Immigrants and in Londoners’, Lancet, no. 217 (17 July 1954), 132–7: 135. In another relatively rare discussion of the issue of Celtic susceptibility by Irish medical men, John A. Musgrave also dismissed the idea claiming that ‘the higher Celtic rates are due in no small measure to the disease having been more recently generally distributed amongst them’. See ‘Tuberculosis and the Celtic Myth’, in the Irish Journal of Medical Science no. 90 (June 1933), 239–51: 250. 33. The influence of the idea of race in relationship to tuberculosis is discussed in Mark Harrison and Michael Worboys, ‘A Disease of Civilisation. Tuberculosis in Britain, Africa and India, 1900-39.’ in Lara Marks and Michael Worboys (eds.) Migrants, Minorities and Health (London: Routledge, 1997), 93–124; and Michael Worboys ‘Tuberculosis and Race in Britain and its Empire, 1900-1950’, in W. Ernst and B. Harris (eds), Race, Science and Medicine (London: Routledge, 1999), 144–166. This deals primarily with the colonial races of the British Empire. 34. See John Crofton and Andrew Douglas, Respiratory Diseases 55

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(Oxford: Blackwell Scientific Publications, 3rd edition, 1981), 17 and for South Africa, Randall M. Packard, White Plague, Black Labor. Tuberculosis and the Political Economy of Health and Disease in South Africa (Berkeley: University of California Press, 1989). 35. See chapters 5 and 8 for Price’s involvement in the anti tuberculosis campaign. 36. See Michael Worboys, ‘Tuberculosis and Race in Britain and its Empire’, in W. Ernst and B. Harris, op. cit. (note 33). 37. Neil McFarlane Tuberculosis in Scotland 1870-1960 (unpublished Ph.D., University of Glasgow, 1990), 188–9 (quoted from R S Doig. A Century of Tuberculosis in Lewis ). 38. Barbara Bates, Bargaining for Life A Social History of Tuberculosis 1876-1938 (Philadelphia: University of Pennsylvania Press, 1992), 322–3. For her discussion of the high rate of TB among American blacks in Philadelphia, see also ibid., 325. 39. Letter, Osler to Aberdeen 2 September 1909. Women’s National Health Association, Correspondence, Peamount Hospital Archives. (uncatalogued). In fact, although the young men and women Osler observed leaving Ireland were healthy, they were not noticeably more immune to the disease than those they left behind, as the subsequent history of their tuberculosis mortality in their host country showed. 40. Ruth Russell, What’s the Matter with Ireland? (New York: the Devin- Adair Co., 1920), 34. The original reference is to discussions in Ishbel Gorden, Countess of Aberdeen, op. cit. (note 28). 41. Annual Report of the Registrar General of Ireland for 1911 . PP 1912- 13 vol XIV, Cd 6313, 33 . 42. J. C. H. and I. M. Gorden, Marquis and Marchioness of Aberdeen, More Crack with “We Twa” (London: Methuen, 1929), 170–1. 43. Dr Michael Flynn, County West Meath, ‘Two Aspects of TB’ Report of the Annual Conference of the British TB Association, Lancet, vol. 2 (9 July 1955), 82–3: 84. 44. Worboys estimates the tuberculosis death rate per 100,000 at c.400 for Irish immigrants to the United States as a whole and around 600 in certain districts of New York and Boston in the 1900s, op. cit. (note 33), 6. It was over 400 for Dublin County Borough 1901-10 and would have been much higher in certain socially disadvantaged areas of the city. R. E .Kennedy estimates the rate of mortality in 1920 in New York for pulmonary TB for persons with Irish born mothers to be 195 per 100,000. R. E. Kennedy, The Irish Emigration, Marriage and Fertilit y, op. cit. (note 29), 50, Table 8. 45. David Fitzpatrick, Irish Emigration 1801-1921 , Studies in Irish Economic and Social History (Dublin: Dundalgan Press, 1990, 1984 56

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edn.), 5–6. 46. Arthur Newsholme, ‘Poverty and Disease, as illustrated by the Course of Typhus Fever and Phthisis in Ireland’, Presidential Address to the Epidemiological Section of the Royal Society of Medicine October 25 1907. Proceedings of the Royal Society of Medicine vol. 1 part 1 (1907-8), 1–44: 23–4. 47. D. H. Akenson, ‘Pre-University Education: 1870-1921’ in W.E. Vaughan (ed.) A New History of Ireland VI: Ireland Under the Union, II 1870-1931 (Oxford: Oxford University Press, 1996), 524–5. 48. Liam Kennedy, Colonialism, Religion and Nationality in Ireland (Belfast: Institute of Irish Studies, 1996), 170. 49. Simon Szreter discusses the development of the modern class-based census in ‘The official representation of social classes in Britain, United States and France: the professional model and “les cadres”.’ Comparative Studies in Society and History vol. 35 (1993), 285–317 and, at greater length, in Fertility, Class and Gender in Britain 1860- 1940 (Cambridge: Cambridge University Press, 1996). Szreter points to the fact that Grimshaw had developed a prototype social class table of disease for Dublin in the 1880s. This appears in subsequent Registrar General Reports for Ireland up to and including 1911. The social classification used for the first time in the census of England and Wales in 1911, was based on a pyramid of occupations with the professionals, higher management and business owners at the peak. This fits in with a meritocratic view of social hierarchy but there are possible alternatives that could have been chosen, including systems based upon wealth and property ownership rather than occupation.The reasons why this particular system was chosen is discussed in Szreter ibid. passim . 50. For a discussion of the concept of ‘poverty’ in the late-nineteenth century see Gertrude Himmelfarb, Poverty and Compassion : The Moral Imagination of the ‘Late Victorians’ (New York: Alfred Knopf 1991), chapters 6-12. 51. See E. D. Mapother’s calculations for Dublin which relate density of population to mortality from disease. Lectures on Public Health, (Dublin: Fannin and Co., 1864), 1867 edn., 21–22. Mapother also reproduces a table for London demonstrating a connection between density and mortality from lung diseases. In 1911 William Burns, Dispensary Medical Officer for Belfast Urban District 15, drew up a table on the prevalence of mortality from phthisis in four districts of Belfast graded-although largely by impression- according to the numbers of mill workers in it. It was reproduced in the Report of the Commissioners, Inspectors and Others on Humidity and Ventilation in: 57

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Flax and Linen Factories PP 1914 vol. XXXVI Cd. 7433 and Cd. 7448 Minutes of Evidence, 241: Urban XIIPop. 38,076 very few mill workers Urban IIIPop. 50,032 large number of mill workers Urban VPop. 16,112 largely mill workers Urban XIPop. 22,669 practically all mill workers

DensityGeneral Mortality from Mortality from personsMortality Diseases of Pulmonary TB to acre per 100,000 Respiratory System per 100,000 per 100,000 XII 36 172 275 244 III 70 176.8 227 249 V 112 231.5 290 266 X1 106 233.8 180 317 Belfast 26.3 172 200 207

52. Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick, Britain, 1800-1854 (Cambridge: Cambridge University Press, 1998) discusses this conflict and how it shaped the direction of the public health movement in Britain. 53. See Szreter, Fertility, Class and Gender , op. cit. (note 49), 80–84. 54. This classification differed from that of the Irish Census itself from 1881–1911. The main economic divisions into which the population were grouped were based on sector. They were professional class, domestic class, agricultural class, industrial class and indefinite and non productive class. 55. T.W. Grimshaw, ‘Class Mortality Statistics’, British Medical Journal vol. 2 (August 13 1887), 340–3: 341. 56. Approximately a quarter (3,095) of the 11,696 who died from phthisis in Dublin 1901-10 died in the workhouse. 57. F.B. Smith, op. cit. (note 29), 212–18. 58. See the next chapter for a discussion of TB in Belfast and Dublin. 59. For Arthur Newsholme (1857-1934) see Chapter 1, fn 23 and 24. 60. Newsholme, op. cit. (note 46), 26 61. Leonard G. Wilson, ‘The Historical Decline of Tuberculosis in Europe and America: The Causes and Significance’, Journal of the History of Medicine and the Allied Sciences , vol. 45 (1990), 366–96: 384. For further discussion of Newsholme’s thesis on Ireland see John M. Eyler, Sir Arthur Newsholme and State Medicine 1885-1935 (Cambridge: Cambridge University Press, 1997), 168–188. 62. The numbers of dispensary tickets issued in 1888 was 594,660. In 58

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1900 it was 638,986. See Poor Law Commission (Ireland) Annual Report, vol. 35 (1900). The proportion per 1,000 of the population in workhouses both sick and able bodied (using figures for workhouse inmates on 1 January of the relevant year) was 9 per 1,000 in 1870,9.7 per 1,000 in 1900 and 8.4 per 1,000 in 1911. Source Report of the Local Government Board (Ireland) 1890 , 7, The Poor Law Commission Annual Report , vol. 35 (1900), xix and ibid. vol. 39 (1914), xx. 63. In 1910 cited as the peak year in England and Wales by M. A. Crowther, The Workhouse System 1834-1929 (London: Batsford Academic, 1981), 59. 7.8 per l,000 of the population were in receipt of indoor relief. In Ireland in the same year the figure was 10.5 per 1,000. 64. Since 1817, Ireland had a system of public county asylums. In 1870 they had a total of approximately 7,000 inmates and in 1914 21,000. See Mark Finnane, Insanity and the Insane in Post Famine Ireland (London: Croom Helm, 1981), 53. 65. If asylum and workhouse inmates are added together in 1910, around 1 in 73 of Ireland’s population was institutionalised. This figure is not very far from that given by Newsholme himself when he calculated the relative degrees of institutionalisation across the British Isles and arrived at figure in 1901 of 1 in 96 for England and Wales, 1 in 137 for Scotland and 1 in 69 for Ireland. See Newsholme, ‘The Relative Importance of the Constituent Factors’, Transactions of the Epidemiological Society of London vol. 25 (1905-6), 31–140: 71. 66. Newsholme, ibid., 79. 67. In Cork workhouse, 1888-1901, the average duration of stay of TB patients was 59.7 days. See Cork Workhouse Register, Cork Archives Institute. In Belfast workhouse, 1872-91, it was 113 days (PRONI BG7.KA 1–4). In the rural workhouses of Lismore and Rathdown however the average stay for TB patients was respectively, 1899- 1922, 244.9 days and between 1888-1899, 213.8 days. (National Archives, Dublin BG 111 and BA 137 KA1-2). The records do not form a continuous series. 68. In Irish asylums the death rate from consumption was 196 per 100,000 in 1895. It was 142 in England and Wales. See F. G. Crookshank, ‘The Frequency of Phthisis Pulmonalis in Asylums’, Journal of Mental Science vol. 45 (1899), 657–83, 660. The death rate for consumption in Irish workhouses was 190 per 100,000 in 1871, 293 in 1891 and 295.7 in 1910-11. (Calculated from the number of residents on the 1 January, Annual Reports of the LGB 59

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(Ireland). Although the death rate for phthisis in Ireland fell from 1904 it increased in the workhouse (see Appendix 4) probably indicating greater efforts to segregate the tubercular poor in response to the campaign against TB which got under way in the 1890s. (See the chapter on the Public Health Campaign). 69. Linda Bryder, ‘Comments on “The Historical Decline of Tuberculosis in Europe and America. Its Causes and Significance”’, Correspondence in Journal of the History of Medicine and the Allied Sciences vol. 46 (1991), 358–62. 70. Leonard Wilson, reply to Bryder, ibid., 362–8. 71. See chapter 7 on sanatorium provision and chapter 3 Appendix 1, on rates of mortality from tuberculosis in Dublin and Belfast. 72. Ruth Barrington in her discussion the development of the Irish poor law and health service, Health, Medicine and Politics in Ireland, 1900-70 (Dublin: Institute of Public Administration, 1987), 5, considers that ‘unlike workhouses in England and Wales, institutions were built with an infirmary for male and female persons and a medical officer appointed to supervise its operations’. These infirmaries were open to the general public in 1862 and, in addition, the boards of guardians had the right to send patients at public cost to voluntary hospitals or the county infirmary. (In 1841 there were 39 county infirmaries funded by county grants and public subscriptions). Under an act of the Irish parliament in the 18th century, the committees of management could make these available to poor people. In 1898 management of these county infirmaries went under the newly created county councils. 73. Edward Dillon Mapother was the son of Roscommon bank official. He was educated at the College of Surgeons, Carmichael School of Medicine and Queen’s College, Galway graduating from there in 1857. His son was Edward Mapother a psychiatrist at the Maudsley Hospital, London. 74. Edward Dillon Mapother, The Unhealthiness of Irish Towns and the Want of Sanitary Legislation (Dublin: Richard Webb and Sons 1866), 18. (Paper read before the Statistical and Social Enquiry Society of Ireland, 19 December 1865). 75. Newsholme, op. cit. (note 46), 20–22. Tables are given showing that although mortality from the chief epidemic diseases was dropping in Ireland in the late-nineteenth century, Ireland’s mortality rates were still higher than England and Wales although approaching parity.

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Deaths from the Principal Epidemic Diseases,Ireland. (smallpox,measles, scarlet fever,typhus, whooping cough,diphtheria, pyrexia (unknown origin),enteric fever,diahorrea.)

Average annual rate per 100,000 for each decade.

1871-80 217 1881-90 143 1891-1900 125 1901-1910 92

76. See chapter 1 for the figures on zymotic disease. 77. Report of the Committee appointed by the Local Government Board for Ireland to inquire into the public health of the City of Dublin , PP1900 vol. XXXIX Cd. 244 and Minutes of Evidence Cd. 243. 78. A comprehensive modern history of the public health system for the whole of nineteenth century Ireland does not exist. 79. Simon Szreter has argued that for the rigorous, pro-active enforcement of public hygiene and environmental improvement to take place, a change in the political character of local government was needed. In England and Wales this happened with the 1869 Local Government Act which created a working-class electorate at municipal level. Where the political circumstances were favourable, an alliance of urban professionals, larger businessmen and the working-class electorate, was able to overcome the objections of lower middle-class rate-payers to public spending for sanitary reform. This new political dispensation created a ‘reform’ movement in certain urban areas of which Chamberlain’s ‘municipal socialism’ in Birmingham was an example. See Simon Szreter, unpublished paper given at the Society for Social Medicine Annual Conference held at the Middlesex Hospital London, 31 March 1995. 80. See Mary E. Daly, Dublin: The Deposed Capital (Cork: Cork University Press, 1984), 276. The chief sanitary officer for Dublin, Charles Cameron, bullied and harassed Dublin corporation in the early-1900s over their reluctance to spend public money in the fight against tuberculosis. Forty years later James Deeny, chief medical adviser to the Eire Local Government Board and Department of Public Health, engaged in a similar irritable correspondence with Dublin Corporation over their parsimony in the running of their tuberculosis service. 81. See Anne Hardy, The Epidemic Streets. Infectious Disease and the Rise 61

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of Preventive Medicine (Oxford: Clarendon Press, 1993), 211–66. 82. T. W. Grimshaw, J. Emerson Reynolds, Robert Furlong and J. W. Moore, The Manual of Public Health (Dublin: Fannin and Co., 1875), 179. The authors suggested that low lying pervious soils gave rise to high rates of consumption and high lying impervious soils to lower rates and that drainage might diminish phthisis. The Manual of Public Health treated consumption as a public health problem which could be tackled by sanitary reform based upon McCormac’s exposition of the deleterious effects of rebreathed air. The authors listed heredity, debility and insanitary conditions as the factors predisposing the individual to consumption and ‘While we do not go as far as MacCormac we admit that the most potent single cause of phthisis is constant inhalation of impure air’, 179. 83. Dublin Journal of Medical Science , vol. 64 (1877), 122.

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