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| Rotunda Hospital, Dublin (RCPI Archival collections: VM/1/4/19) |
The establishment of the voluntary hospitals
The early eighteenth century saw the
establishment of voluntary hospitals by philanthropists, mainly in Dublin but
also in the larger provincial towns. Jervis Street hospital (the Charitable
Infirmary) was the first voluntary hospital Ireland and was founded in
1718. Many of these, like Dr. Steeven’s Hospital
(founded in 1733) and Mercer’s (founded 1734) would survive into the twentieth century. The eighteenth century also saw
the establishment of specialist hospitals, most of them voluntary, such as the
Rotunda Lying In Hospital, founded in 1745, St. Patrick’s Hospital for mental
illness, founded in 1747 and the Westmoreland Lock Hospital, for the treatment
of venereal disease, in 1792.
A modern public health service at county level
began in 1765 when a parliamentary enactment provided for the erection and
support of an infirmary for each county in Ireland and also permitted support
for several existing hospitals, mainly in Dublin and Cork, out of public funds.
The county infirmaries were to be
maintained by grand jury presentments, parliamentary grants and local
subscriptions. The grand juries were groups of landowners who were called
together by the High Sheriff in each county twice a year for legal and local
administrative reasons.
The House of Industry hospitals, district lunatic asylums and medical dispensaries
The Dublin house of industry, a precursor
of the workhouses of the nineteenth century, was founded in 1772. This
institution became in time a vast concern, providing hospitals for the sick, an
asylum for children, bridewells, penitentiaries for women and young criminals,
a house of industry for vagrants, and cells for lunatics. From it evolved the House of Industry
hospitals – the Richmond, Whitworth and Hardwicke - and it played a major role
in establishing the first and largest of the public lunatic asylums – the
Richmond Lunatic Asylum – which opened for patients in 1814. Following the
report of the Committee on the Lunatic Poor in 1817, the Lord Lieutenant was
enabled by statute to build asylums where he considered necessary and, over the
next half century, a well-developed mental health infrastructure was in place.
By 1871, twenty two asylums were being financially supported by the grand
juries. In 1850 a central asylum “for insane persons charged with offences in
Ireland” was opened in Dundrum. This institution, the first criminal lunatic
asylum in these islands, was under the direct control of the Lord Lieutenant
who appointed the staff and made regulations for its management.
A few dispensaries were supported by
voluntary subscriptions in several of the larger towns and cities from the late
eighteenth century, but it was not until 1805 that grand juries were authorised
to give grants to dispensaries in rural areas. By the early 1830s, there were
450 dispensaries throughout the country, administered by committees of
management and supported partly by subscriptions and partly by grand jury grants.
There were fewer dispensaries in poorer areas, where voluntary contributions
were wanting, and where it was difficult to raise enough money to start them.
Inadequate as many of these dispensaries were, they represented the first steps
towards domiciliary medical treatment of the rural population.
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| Robert Graves (1796-1853) (RCPI Archival collections: VM/1/2/S/35) |
The impact of epidemics on the development of medical infrastructure
Epidemic disease was a major impetus in the
development of a medical infrastructure. Typhus was a major scourge in Ireland
in the early nineteenth century and, while several fever hospitals had been
established in the larger towns in the late eighteenth century, it was not
until 1807 that legislation was passed to encourage their construction
throughout the country. A fever epidemic of unprecedented proportions raged in
Ireland between 1816 and 1819. Under an 1818 Act, local boards of health could
be established, supported partly by grand juries, which had extensive powers to
combat disease. Grand juries were empowered to make presentments equal to twice
the amount raised by private subscription to build fever hospitals. In 1819,
legislation enabled officers of health to be appointed in parishes and a parish
health tax could be levied.
The establishment of the Central Board of Health in
1820 marked a major step in the centralisation of medical relief and local
boards of health were to play a major role in combating epidemics over the
following decades. The Central Board of Health collected statistics about local
health conditions, advised where local boards of health should be established
and when grant to hospitals should be made. When cholera broke out in Ireland
in March 1832, the Central Board of Health, renamed the Cholera Board for the
duration of the epidemic, supervised measures to combat the disease which
included the establishment of local boards of health.
Dublin hospitals like the
Meath were at the forefront of the fight against infectious disease from the
1820s and introduced new methods of bedside clinical training to the English
speaking world. The census commissioners
noted in 1854 that to these metropolitan hospitals “the Irish School of Medicine
is largely indebted for the celebrity which it has so long enjoyed”. The Meath
hospital received international recognition in the early nineteenth century due
to the innovative teaching methods and research carried out by its physicians,
Robert Graves and William Stokes. The latter had survived an attack of typhus
in 1827 and identified the first case of cholera in Ireland in 1832. This new
approach to clinical training had originated on the continent and its
introduction into the Meath hospital heralded what has been described as the
heroic age of the Irish School of Medicine. The voluntary hospital
infrastructure continued to expand during the nineteenth century and following
Catholic Emancipation many Catholic religious orders became involved in
founding hospitals.
The Irish Poor Law, 1838
The enactment of the Irish Poor Law of 1838
was to have a dramatic effect on the provision of public health services for
the rest of the nineteenth century. The country was divided into over one
hundred and fifty poor law unions each with a workhouse at its centre and
administered by a board of guardians.The structure of the poor law system, being
modern and efficient and more easily subject to central control, was adapted on
nearly all occasions where a new local function was created or an old one
modified .The Medical Charities Act of 1851 led to the modernisation and
extension of the old grand jury dispensary network under the boards of
guardians and made a domiciliary medical service available to large sections of
the population, the destitute poor, for the first time.
By 1852, every poor law
union had been divided into a number of dispensary districts, each with a
dispensary and medical officer. Patients
had to apply to a poor law guardian for a ticket every time they wanted to
attend a dispensary free of charge. Committees of management were responsible
to the boards of guardians for the management of the dispensaries and
appointing the dispensary doctors. In 1863, the dispensary doctors were made
registrars of births and deaths and of Roman Catholic marriages and the
practice of registering births, marriages and deaths was standardised on the 1st
of January 1864. When registering deaths, the dispensary doctors were required
to note the cause of death and duration of illness, thus enabling accurate
statistics of mortality to be compiled for the first time. The registration of
births enabled such measures as the compulsory vaccination of children against
smallpox to be carried out effectively and by the end of the nineteenth century
this scourge had, to a great extent, been eliminated.
While many boards of guardians had allowed
the non-destitute to enter workhouse hospitals for treatment during the 1850s,
the 1862 Poor Law (Amendment) Act officially opened the workhouse hospitals to
the non-destitute sick. As a result of these developments, Ireland
had one of the most advanced health services in Europe in the mid-nineteenth
century, if policy and structure are to be taken as criteria. The Local government (Ireland) Act, 1898,
replaced the grand juries by democratically elected county and rural district
councils. The county councils took over the administration, either directly or
through joint committees, of the district lunatic asylums.
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| Newcastle Sanatorium, Wicklow. Image courtesy of NLI (L_ROY_05467) |
Tuberculosis and the sanatorium
While Ireland had a low death rate from
infectious disease in the first decade of the twentieth century,
tuberculosis was the marked exception. The last years of the nineteenth century
saw the first attacks made against the disease with the establishment of
Newcastle Sanatorium in 1893. In 1904, the sanitary authorities of County Cork
combined with Cork Corporation to establish Heatherside Sanatorium near
Doneraile. In 1907, the Dublin City and County authorities established
Crooksling Sanatorium. A Tuberculosis Prevention Act was passed in 1908 which
gave the county councils power to provide sanatoria and brought the first
veterinary inspectors into the employment of the sanitary authorities. Peamount Sanatorium was founded in 1912
through the efforts of the Women’s National Health Association, the most
formidable health pressure group of the early twentieth century.
Public health provision in post-independent Ireland
The turbulent years of the early 1920s saw
some revolutionary changes in the public health system. In general, the boards
of guardians outside Dublin were abolished and were replaced by county boards
of health and public assistance, essentially sub-committees of the county
councils. Most workhouses were closed to save money and central institutions
called county homes were established in each county where the poor were to be
relieved. While the newly styled county homes were to be reserved in theory for
the old and infirm many soon included unmarried mothers, children and the
mentally retarded. Following the
establishment of the Irish Free State the Department of Local Government and
Public Health formally became, in 1924, the central government authority for
local government and health administration. The Minister took over the Lord
Lieutenant’s duties in relation to the mental hospitals. In 1930, the establishment of the Irish Hospitals
Sweepstakes, a lottery to provide financial assistance to hospitals, provided a
financial lifeline to many voluntary hospitals who were struggling to survive
following a reduction in the number of endowments and bequests after the Great
War.
The post-war period and declining mortality
There were significant developments in
health care in the 1940s and 1950s. The Mental Health Treatment Act of 1945
modernised the legal code under which the mental services operated and provided
important safeguards against the arbitrary detention of patients although the
numbers of persons being treated continued to increase until, by 1959, there
were 20,000 patients in Irish mental hospitals. In the years immediately after 1945 there was
a major effort to develop anti-tuberculosis services. The Tuberculosis
(Establishment of Sanitoria) Act of 1945 permitted the Minister for Local
Government and Public Health to arrange for the building of sanatoria and to
transfer these to local authorities when completed. This was a major departure
from established practice for the central authority as it stepped outside its
normal functions of directing and co-ordinating the local services. Sanatoria
were built at Dublin, Cork and Galway and were handed over when completed to
the local authorities as was provided under the Act.
There was also widespread
building and conversion of buildings for the treatment of tuberculosis cases by
local authorities. These developments,
together with the payment of maintenance allowances for dependents of persons
undergoing treatment for infectious disease, mass radiography, BCG vaccination
and new drugs such as streptomycin, led to a great decline in mortality for the
disease and in the number of new cases appearing. In 1947 the Department of Local Government
and Public Health was divided into two separate departments. The Health Act of 1953 extended eligibility
for general hospital services and maternity care to a much wider class. Health
authorities were now required to provide child welfare clinic services and the
school health service was improved. The dispensary service and dispensary
doctors were transferred from the public assistance code to the health
authorities. The old dispensary ticket system was done away with and replaced
by medical cards. A more liberal code for the governing of county homes was
introduced and provision was made for the development of a comprehensive
rehabilitation service.
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| William Stokes (1804-78) and William Wilde (1815-76) (RCPI Archival Collections: PDH/6/2/12) |
1970s regionalisation and the Irish 'love affair' with the hospital bed
By the 1960s, it was felt that as the state
had taken over the major financial interest in the health service there should
be a new administrative framework combining national and local interests. For technical and logistical reasons it was
believed that better services could be provided on a regional rather than a
county basis. The establishment of the
health boards under the Health Act, 1970, marked a major break in the link
between the health services and county administration. At this time Ireland had
the highest proportion of hospital beds to population in western Europe and the
Irish hospital system was described as “one of a large number of small
institutions scattered throughout the country”. The following decades would see
the closure or amalgamation of many voluntary and state hospitals into larger
units and the dismantling of the old mental hospital infrastructure.
The historical value of Irish hospital records
That Irish hospital records are of great
historical interest has long been acknowledged. Dr. William Wilde, the internationally
renowned nineteenth century physician and statistician, recognised one hundred
and seventy years ago that the hospital registers of the Rotunda Hospital represented
the ‘most interesting and earliest statistical tables on record’. Ireland’s medical institutions, both voluntary
and public, have a peculiarly rich and varied history and have played a
paramount role in medical advances over the last three centuries. While some collections of hospital archives
are now safe in archival custody, many collections remain in peril. These
archives have no protection under the law and it is often only through the good
offices of interested hospital staff that material has been preserved.
Brian Donnelly is a Senior Archivist at the National Archives with responsibility for Business and Hospital records. Images courtesy of Fergus Brády, Archivist, RCPI.
