2 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 29 Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones 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. To 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 Political 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 31 Greta Jones - 9789004333413 Downloaded from Brill.com10/02/2021 06:56:24PM via free access Greta Jones 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.