Parochial Officers of Health in pre-Famine Dublin by Ciarán McCabe

In this month's blog Dr Ciaran McCabe, an Irish Research Council funded postdoctoral fellow  (NUI Galway), considers the oft-neglected figure of the parochial health officer and his role in the prevention of contagion and fighting fever epidemics in early nineteenth-century Ireland. In 2011, Dr McCabe successfully completed a MA thesis at the Centre for the History of Medicine in Ireland, UCD, on the impact of the 1817-19 and 1826-27 fever epidemics on the Cork Street Fever Hospital, Dublin. 

Preventing the Danger of Contagion and Other Evils

The Fever Act of 1819 empowered parish 

vestries to elect unpaid officers of health

From the middle of the seventeenth century, civil parish vestries in Ireland carried out functions which we would today associate with local government services: fire-fighting, tree planting, public lighting, and the repair of roads. Parishes also undertook to provide some assistance to local parishioners in distress and this relief included the support of local 'foundlings', the purchase of coffins for local paupers, payments of cash to widows and the maintenance of an alms-house, typically inhabited by local widows. Parish vestries were of such importance as units of local government that it was upon them that powers were bestowed for the prevention of contagion in response to the 1817-19 fever epidemic. The 1819 Fever Act empowered parish vestries to elect unpaid officers of health, who had the authority to direct that tenements, lanes and streets be cleaned, and that nuisances be removed from the streets. These officers also had the power to apprehend and dismiss from the parish 'all idle poor Persons, Men, Women, or Children, and all Persons who may be found begging or seeking Relief' in the interest of 'preventing the Danger of Contagion and other Evils'.¹

Officers of Health: Respectable Parishioners

The positions of officers of health were filled by respectable parishioners, who also typically served as churchwardens, sidesmen and overseers. To these men (and they were invariably men), such voluntary service gave them an opportunity to display their civil responsibilities, as well as asserting their prominence within the community. Toby Barnard has argued that 'as in England, so in Protestant Ireland, a willingness regularly to assume the burdens of parochial office may have helped the middling sort to define and so distinguish themselves from the lower ranks'.² Among the officers of health in St Michan's parish in the 1830s were Mark Flower of Old Church Street and merchant William Hill of 47 Pill Lane, who also served together as sidesmen and overseers of licenced houses.³ In some instances, parishioners who were qualified medical practitioners  were elected to serve as officers of health, such as David Brereton MD in St Michan's in 1831.⁴ In St Thomas's parish in 1828, four of the ten elected officers of health were medical practitioners.⁵

The Fever Act (1819)

A notice issued by the officers of
health in St Werburgh parish,
November 1831

The Fever Act was passed in June 1819, by which point the nationwide fever epidemic had petered out. With the emergency over, parishes were slow to fill the positions of officers of health, which, while not encompassing any salary, required the levying of a parish cess to cover expenses. Shortly after the legislation was passed, the Head of Police wrote to each of the Dublin parishes, reminding them of of their duties to elect officers under the new Fever Act.⁶ In St Catherine's the first officers of health were appointed two months after the legislation was passed while it took nine months for the first officers to be appointed in St Werburgh's parish.⁷ Such delays could be criticised, yet on the other hand, given that the worst of the epidemic had passed, parishes were understandably reluctant to assume additional expenditure on unnecessary undertakings.

Cholera Epidemic

Freeman’s Journal, 17 November 1831. The parish vestry 

of St Anne’s in Dublin city appointed officers of health in 

late-1831, following reports that cholera had reached

 England and was believed likely to spread to Ireland

For the first decade after the enactment of the 1819 fever legislation, many parishes avoided filling these positions. Parish expenditure had to be raised through the taxation of local parishioners, who, in some cases in Dublin city, paid up to sixteen different taxes to various local authorities.⁸ The significance of the 1819 Fever Act, empowering parish vestries to spearhead the local responses to epidemic disease, was not realised until more than a decade after its enactment, when cholera made its first appearance in western Europe. In late-1831, when reports reached Ireland that cholera had been identified in England, parish vestries throughout the country held emergency meetings, drawing on their powers under the 1819 act and rapidly appointing officers of health as a measure to prevent – albeit unsuccessfully – the introduction and propagation of cholera.

To Guard Against Contagion

In St Andrew's parish in December 1831, a cess was levied on parishioners to enable the work of the officers of health by means of 'cleansing & whitewashing the dwellings of the poor in order to guard against contagion'.⁹ Two weeks earlier in St Catherine's parish, the sum of £50 was levied on parishioners following reports 'that a pestilential has raged in several parts of Europe form sometime under the name of Cholera Morbus, which it is feared may shortly extend its ravages to this Kingdom'.¹⁰ Cholera eventually reached Ireland in the spring of 1832 and throughout the epidemic, parochial officers of health carried out measures to mitigate the impact of the contagion. A question which remains unanswered is how the parochial officers of health interacted with other authorities, such as the state-run Board of Health. The rejection in October 1832 by officers of St James's parish of the Board of Health's right to interfere in parochial matters suggests the existence of inherent tensions between these parties, yet the extent to which this single instance is representative of a wider trend is as of yet unclear.¹¹

A dead cholera victim in Sunderland, 1832. Following the outbreak of cholera in north-east
England, Irish parish vestries rushed to appoint officers of health. Wellcome Images

The Decline of the Parochial Officer of Health

Some parishes continued to appoint officers of health throughout the 1830s but the practice declined by the 1840s; yet there are some instances of officers being appointed by parishes in Ulster into the 1850s.¹² The power of parish vestries to appoint officers of health was repealed by the 1866 Sanitary Act,¹³ which extended earlier legislation for England to Ireland and was passed at the height of yet another cholera epidemic. Responsibility for sanitary regulations was transferred to a new Public Health Committee, which operated under the auspices of Dublin Corporation.¹⁴ As well as reflecting wider developments in public health reform in this period, the decline of the parochial officer of health was also a symptom of the gradual removal of civil functions from Irish parish vestries. Although constituting relatively short-lived positions with limited powers, and whose efficacy in mitigating the impact of contagion is difficult to gauge, parochial officers of health remain an interesting and neglected part of the social and medical landscape of nineteenth-century Ireland.

Dr Ciarán McCabe

Dr Ciarán McCabe is an Irish Research Council Government of Ireland postdoctoral fellow at the Moore Institute, NUI Galway. In 2015 he was awarded a PhD by Maynooth University for his thesis which examined begging and alms-giving in pre-Famine Ireland. He is currently writing a monograph arising from his doctoral research. Dr McCabe holds a Masters in the Social and Cultural History of Medicine from the Centre for the History of Medicine in Ireland (CHOMI), UCD and also serves as compiler for Irish History Online.

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1 An act to establish Regulations for preventing Contagious Diseases in Ireland', 59 Geo. III, c. 41 (14 June 1819).^↩
2 Toby Barnard, A New Anatomy of Ireland: The Irish Protestants, 1649-1770 (New Haven and London), 2003), p. 242.^↩
3 St Michan's parish, Dublin, vestry minute book, 7 April 1828 (Representative Church Body Library (RCBL), St Michan's parish, Dublin, vestry minute books, P 276.05.5; ibid., 23 December 1828; ibid., 9 April 1832; 20 April 1835. Hill also served as churchwarden: ibid., 4 April 1836.^↩
4 St Michan's parish, Dublin, vestry minute book, 23 November 1831.^↩
5 St Thomas parish, Dublin, vestry minute book, 7 April 1828 (RCBL, St Thomas's parish, Dublin, vestry minute books, P 80.5.2).^↩
6 Saunder's Newsletter, 19 August 1819.^↩
7 St Catherine's parish, Dublin, vestry minutes, 24 August 1819 (RCBL, St Catherine's parish, Dublin, vestry minute books, P 117.05.7); St Werburgh's parish, Dublin, vestry minutes, 25 March 1820 (RCBL, St Werburgh's parish, Dublin, vestry minute books, P 326.05.2).^↩
8 Jacinta Prunty, Dublin Slums, 1800-1925: A Study in Urban Geography (Dublin, 1998), p. 67.^↩
9 St Andrew's parish, Dublin, vestry minutes, 12 December 1831 (RCBL, St Andrew's parish, Dublin vestry minute books, P 059.05.2).^↩
10 St Catherine's parish, Dublin, vestry minutes, 28 November 1831.^↩
11 The Pilot, 12 October 1832.^↩
12 Belfast Newsletter, 28 August 1851, 14 April 1852, 3 May 1854.^↩
13 'An act to amend the Law relating to Public Health', 29 & 30 Vict., c. 90, s. 69 (7 August 1866).^↩
14 Prunty, Dublin Slums, pp 70-71.^↩

AIDS and History by David Kilgannon

In this month's blog post, David Kilgannon, a Wellcome Trust funded PhD candidate in the Department of History, NUI Galway, looks at the response of two voluntary organisations, Gay Health Action and the Irish Haemophilia Society, to the arrival of AIDS in 1980s Ireland. In 2015, David completed his Wellcome Trust funded MA on the history of AIDS activism in Ireland at the Centre for the History of Medicine in Ireland, University College Dublin.

First Reported Cases of Aids

Report on the appearance of Kaposi's 

Sarcoma and Pneumocystis Pneumonia 

among homosexual men in New York 

and California, Morbidity and Mortality

Weekly Report, 3 July 1981.  Published

by the Centers for Disease Control and 

Prevention. Public domain.

The first clinical observed cases of AIDS arose among a group of homosexual men in Los Angeles in 1981. All five men presented with Pneumocystis pneumonia, a rare form of pneumonia, which is usually successfully fought off by the human immune system. The increasing prevalence of gay men with impaired immune systems throughout 1981-82 led the US Centers for Disease Control in June 1982 to classify this new disease as Gay Related Immune Deficiency (GRID). However, this model was soon found to be inadequate when non-homosexual patients, including women and children, presented with GRID symptoms. This resulted in the reclassification of the condition as Acquired Immune Deficiency Syndrome, or AIDS, in August 1982.

AIDS: State Response & Policy Failure 

Yet, the initial appearance of AIDS among gay men and intravenous drug users, and its continuing association with these socially marginalised groups was incredibly influential in shaping what were often desultory state responses to the syndrome, with the reaction of national healthcare systems to the incipient epidemic often appearing apathetic and lethargic. For example, in the United States it took a full three years after the first identification of the condition for the Department of Health and Human Services to produce and distribute their first AIDS information booklet for the public. While state responses were often insufficient, the appearance of AIDS instigated a substantial response by voluntary and activists groups. Roy Porter identified this phenomenon as one of the seminal features of the response to the spread of AIDS from the 1980s onwards.

AIDS Activism in Ireland

Number of cases of Sero-positivity in Ireland, 1985-1990

The historical study of AIDS, and AIDS activism in particular, has received sustained historical analysis in the United States and the United Kingdom. However, it has yet to be examined in Ireland. This lacuna is striking, as Ireland arguably presents a distinctive national context relating to AIDS. Three features are particularly notable. The principal prophylactic advocated for AIDS prevention, the condom, had limited availability in Ireland until 1985. Under the Health (Family Planning) Act (1979), anyone wishing to purchase a condom required a doctor's prescription. Secondly, the largest constituent group affected by AIDS in the United States, the gay community, was effectively criminalised in Ireland until 1993. Thirdly, in the 1980s the Irish health service underwent a period of drastic reductions in capacity, losing over a third of hospital beds during this decade. Taken together, these factors make a study of AIDS activism in Ireland particularly worthy of analysis in relation to its counterparts in the broader Anglophone world. My research attempted to examine two such examples of this phenomenon in Ireland. Namely, the activist responses from the gay and haemophilia communities to AIDS, as exemplified through the work of Gay Health Action and the Irish Haemophilia Society. 

Gay Health Action

Number of AIDs cases in Ireland, 1983-1990

The work of Gay Health Action was explored through an examination of their records found in the Irish Queer Archive held at the National Library of Ireland. These sources indicate that Gay Health Action's activism was directly influenced by the international impact and context of AIDS. Articles from the National Gay Federation's magazine Out reveal a community that was quite aware of the devastation of the gay community in other countries. This awareness played a key role in instigating the foundation of Gay Health Action in January 1985 even though AIDS was not yet then a prominent public health threat in Ireland. At that point, only eleven deaths had been attributed to the syndrome in Ireland. Gay Health Action worked to raise awareness by disseminating information on the disorder, producing information leaflets and running education seminars. The group organised itself within the existing structures of the gay community, using already established methods of information dissemination within the community and establishing a telephone helpline that had clear antecedents to earlier forms of gay activism. This led Gay Health Action to take an increasingly prominent role in the management of all matters relating to AIDS in Ireland, speaking as experts on the condition to media and running an information service that superseded the role of the state's Health Education Bureau.

Irish Haemophilia Society

Number of AIDS related deaths in Ireland, 1982-1990

Yet, this form of activist response was not replicated among the varied voluntary groups representing communities that were directly impacted by the advent of AIDS in Ireland. The Irish Haemophilia Society, many of whose members became afflicted with AIDS due to the use of imported blood products which were infected with HIV,  took a quite different approach. As a reading of Lindsay Tribunal Report, the Irish Haemophilia Society's proceedings transcripts, and the society's newsletters reveals, they only began to seriously grapple with the challenge of AIDS following the infection of more than a third of their members. This fact meant that the preventative, public education role fulfilled by an organisation such as Gay Health Action was less relevant to the Irish Haemophilia Society and its members. Instead the organisation focused primarily on providing pastoral care to infected Irish haemophilia sufferers, including supports that assisted those dying from AIDS.

The Voluntary Sector and Epidemic Disease

By examining previously unstudied responses by voluntary groups to an epidemic disease in 1980s Ireland, this project aspires to add greater depth to our knowledge of Irish health policy and the role of the voluntary sector in addressing the challenges associated with an epidemic disease.

David Kilgannon is a PhD researcher in the Department of History in the National University of Ireland (Galway). His project, which is co-supervised by Dr Kevin O'Sullivan and Dr Sarah-Anne Buckley, examines the changing treatment of the disabled in twentieth century Ireland and is funded by the Wellcome Trust. His Master's dissertation, 'How to survive a plague': AIDS activism in Ireland, 1983-1989', examined voluntary sector efforts against the AIDS virus in 1980s Ireland. It was completed in the Centre for the History of Medicine in Ireland, School of History, University College Dublin under the supervision of Dr Catherine Cox.

The Cork Street Fever Hospital Archive by Fergus Brady

In 2013, the Cork Street Fever Hospital archive was donated to the Royal College of Physicians of Ireland (RCPI). Following a recent funding award, the archivists at the RCPI began the process of cataloguing and preserving these extensive and important medical records. The project is now complete and the final collection list is available to browse through the online RCPI catalogue. In this month's post, Fergus Brady, Archivist, RCPI, reports on the archive and outlines the history of this fascinating Irish medical institution.

Nurses and patients on the 'lower landing', Cork Street Fever Hospital, 1903
(RCPI Archival Collections: CSFH/1/2/1/6)

RCPI win Wellcome Trust funding to catalogue Cork Fever Hospital Archive

A project, funded by the Wellcome Trust, to fully catalogue the archive of Cork Street Fever Hospital has been completed by the staff of the Royal College Physicians of Ireland Heritage Centre. As part of the project, appropriate measures were also taken to ensure the long-term preservation of the archive so that the hospital’s records will be accessible to researchers both in the present and into the future.

The origins of the House of Recovery and Fever Hospital, Cork Street, Dublin

Minutes, Governors of Cork Street Fever Hospital, 1801
(RCPI Archival Collections: CSFH/1/1/1)

The House of Recovery and Fever Hospital on Cork Street, Dublin, grew out of a series of meetings held between a group of wealthy and philanthropic men drawn from Anglican and Quaker congregations during October 1801. In the late eighteenth and early nineteenth centuries in Dublin, as elsewhere in Europe, insanitary conditions ensured that infectious diseases were prevalent among the general population. Those present at the October meetings had a clear idea of the nature and scale of such health issues, stating that ‘...no adequate Hospital accommodation has hitherto been provided for the relief of the Sick poor of Dublin afflicted with fever (especially such as may be of a contagious Nature)’. Influenced by the fever hospital movement in Britain, the provisional Committee believed that the solution lay in the ‘establishment of a House of Recovery to which patients on the first appearance of Fever might be removed’.¹

The fever hospital opens

Original entrance to the hospital, erected 1804
(RCPI Archival Collections: CSFH/7/1/6)

Less than three years later, on 14 May 1804, the newly-erected House of Recovery and Fever Hospital on Cork Street admitted its first batch of patients. As its name suggests, the hospital physically separated the sick from the convalescent by the constructing two buildings 116 feet apart in what was an early attempt at infection control.² The erection of such purpose-built buildings was intentional, as the hospital’s founders were influenced by prevailing theories regarding the control of infectious diseases.

Early years and fever epidemics

Cork Street Fever Hospital and House of Recovery, 1899
(RCPI Archival Collections: CSFH/1/2/1/5)

In the early decades of the hospital’s existence its catchment area expanded from the Dublin Liberties to the whole of the city. Hospital buildings were extended to meet the admissions triggered by the regular epidemics which ravaged the poorest districts in the city. A fever epidemic in 1817—1819 put severe pressure on the hospital, with admissions doubling in 1818. In 1826 an epidemic of typhus necessitated the erection of emergency tents. The 1830s and 1840s were periods of exceptional activity, as the number of patients admitted swelled due to outbreaks of cholera and typhus. In 1847 tents were erected and 400 emergency beds provided to allow for the admission of patients suffering from a typhus outbreak, which had been stimulated in large part by the influx into Dublin of thousands of famine-stricken refugees from the countryside. These regular epidemics took their toll on the health of the medical staff, and in particular the nursing staff, many of whom were struck down with fevers contracted during the course of their work.

The 'Red House'

Nurse and two children on the balcony of the Red House, 1909
(RCPI Archival Collections: CSFH1/2/1/6)

In the 1860s and 1870s epidemics of smallpox placed great pressure on the hospital’s resources, with a record case fatality rate of 21 per cent recorded in 1878. In the last few decades of the century measles, typhoid, scarlet fever and smallpox predominated, prompting the hospital governors to build the ‘Red House’ on the grounds of Cork Street, and to open an auxiliary hospital for convalescents at Beneavin, Finglas. In 1891, hospital reports recorded diphtheria for the first time, a disease which became a significant health problem in the early twentieth century with the arrival in Dublin of the virulent gravis strain.

The move to Cherry Orchard

Patient arriving at hospital in ambulance, 1896
(RCPI Archival Collections: CSFH/1/2/1/5)

In the early twentieth century there were two changes that significantly altered the running of the hospital: in 1904, the hospital was granted a Royal Charter under which Dr. John Marshall Day was designated first Medical Superintendent; and, in 1936, the Dublin Fever Hospital Act changed the hospital from voluntary to municipal control. This alteration sought to “make provision for the establishment of a new fever hospital in or near the city of Dublin and for the closing of the House of Recovery and Fever Hospital, Cork Street, Dublin”.³ Planning for the development of a new hospital was long and protracted, however, with both the Second Word War and a 1944 sworn inquiry into alleged maladministration in the hospital contributing to delays. Led by the efforts of Dr. Day’s successor as Medical Superintendent, Dr. C. J. McSweeney, a 74-acre site was finally secured at Blackditch, Palmerstown, Co. Dublin, and building tenders received in early 1950. The hospital board decided that as the name Blackditch evoked images of plague and death, the address of the new hospital should be changed to Cherry Orchard. In November 1953, patients and staff vacated the premises at Cork Street and moved to the new House of Recovery and Dublin Fever Hospital, Cherry Orchard.

The Cork Street Fever Hospital archive

Staff of Cork Street Fever Hospital, 1938
Dr. C. J. McSweeney, Medical Superintendent, is
pictured sixth from the right in the second row
(RCPI Archival Collections: CSFH/1/3/4/1) 

The archive of Cork Street Fever Hospital is large and varied, and consists of a series of records relating to hospital management, staff, students, patients, finances, buildings, hospital history and events. There are also records of inquiries, routine administration and domestic tasks, and individual Medical Superintendents. The run of minute books is remarkably complete, stretching from the first meetings of the provisional managing committee in 1801 to 1953, a span interrupted only by a gap of twelve years between 1828 and 1842. Similarly annual reports, which usually include medical reports, run from 1801 to 1953 with few omissions. Records relating to individual Medical Superintendents are particularly plentiful for Dr. C. J. McSweeney’s tenure (1934–1953), and consist for the most part in report books, research and teaching notes, drafts of articles and papers, and other ephemera. Patient records are, unfortunately, less comprehensive, with the earliest surviving register of patients dating from 1924 to 1929. Access to patient records and other sensitive files containing personal data are subject to Data Protection legislation and conditions laid out in the RCPI Heritage Centre’s guidelines. There are also some records across the various series which date from the decades following the transfer of the hospital to Cherry Orchard.

If you have any queries about the collection, please contact heritagecentre@rcpi.ie.

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1. Cork Street Fever Hospital Committee Proceedings, 23 October 1801.↩
2. Patricia Conway, Sheila Fitzgerald and Seamus O’Dea, Cherry Orchard Hospital: The First 50 Years (Dublin, 2003), p.  2.↩
3. Ibid., p. 3.↩

The historical development of Irish Hospitals and the importance of their records by Brian Donnelly

In this month's post, Brian Donnelly, senior archivist at the National Archives of Ireland, outlines the development of Irish hospitals from the eighteenth to the twentieth century.

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.

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 1^st 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.

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.

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. 

Cholera in Belfast in 1832 and 1848/49 by Nigel Farrell

On the 28th of February, 1832 at around midnight, Bernard Murtagh, a 34 year old cooper who resided in a lodging house on Quay Lane Belfast, a narrow street near the River Lagan, became violently ill. Described as a man of irregular habits he had been suffering from diarrhoea for two or three days previously but had not complained of any other symptoms when he went to bed following his usual supper of stirabout and milk. Around midnight his condition worsened and towards morning was accompanied with intense cramps and vomiting, the fluid (from both ends) described as whitish and like milk or meal and water. He was seen by Surgeon McBurney the following morning and was found to be in a state of extreme weakness and collapse, extremely cold and without a perceptible pulse at the wrist. A mustard emetic was administered around midday after which he appeared to revive a little. However, this proved only to be a temporary respite and he died between 7 and 8 p.m. that evening some nineteen hours after becoming ill.

High Street Belfast c.1831. A water cart can be seen to the right of the picture

Source: Ulster Museum IC/High St/831

Murtaugh had become the first recognised victim in Ireland to have died from what was then perceived as a new a frightening disease from the East, Asiatic cholera, though in truth it was new only to the West. Cholera, notable for its severity, rapidity and high mortality had been endemic in India in for some time before spreading throughout Asia after 1817 and Europe after 1829. Its signature symptoms, violent vomiting and diarrhoea resembling rice husks were usually accompanied by agonising cramps, muscular spasms, a weakened pulse, low temperature, and a blue tinge to the nails and skin. They were caused by infection with a microorganism, vibrio cholerae, usually following the ingestion of water contaminated by the excreta of another cholera sufferer, particularly in places where infected sewage was able to seep into the public water supply. In the towns and cities of nineteenth century Ireland where sanitary practices and sewage systems were often rudimentary at best this particular method of dissemination was a common and deadly hazard.

In Ireland alone around 40% of those who contracted cholera between 1832 and 33 would die as a consequence and in some areas mortality rates were as high as 76%. In a second outbreak during 1848/49 mortality rates were even higher, with the disease finding easy prey in the form of a population severely weakened by Famine and its associated illnesses. Belfast’s mortality rate at just 16% was however, much more favourable than anywhere else in the country and was significantly lower than Dublin or Cork who experienced rates in excess of 40%.

A Court For King Cholera. This famous cartoon depicts conditions conducive to the spread of cholera.

Source: Wellcome Images

Nineteenth century Belfast was Irelands only industrialised town and outwardly appeared successful and prosperous. Described by one commentator as looking as if it ‘had money in its pocket and roast beef for dinner’. However, while industrialisation had created opportunity, it also created serious social issues particularly in the provision of housing, water supply and sanitation. Housing for the labouring poor was laid out in a grid pattern of confined and insanitary courts, lanes and alleys, commonly consisting of two story buildings occupied by two or more families. Few houses were provided with piped water and over 7,000 houses were supplied from public fountains, by water carts, or from pumps sunk by landlords. Sewers were often constructed to deposit their effluent directly into the town’s main watercourses and high tides and flooding regularly carried effluvia back onto the streets and into the homes of those who lived in their vicinity, making sanitary conditions and their likelihood of contracting serious illnesses inherently worse.

When cholera came however, Belfast appears to have been as well, if not better prepared to combat the disease than most. The initial response was the remit of the Police Commissioners and of an ad hoc and hastily formed Board of Health. Working closely together, a systematic programme of street cleaning and of whitewashing and fumigating houses was instigated. Temporary hospital accommodation was provided in the grounds of the towns Fever Hospital with Dr Henry McCormac placed in charge. McCormac combined a strict isolation policy with treatments which included bloodletting and the administration of calomel (mercury), opiates and dilute sulphuric acid. Though mortality in the hospital was much higher (22%) than for the rest of the town there does appear to have been less resistance in Belfast to the idea of going to hospital than was the case elsewhere. In Dublin for example, opposition was such that carriages carrying the sick to hospital were occasionally set upon, the patients ‘rescued’ and the carriages thrown in the Liffey.

Cholera Localities Belfast 1832

Source: A.G. Malcolm ‘The Sanitary State of Belfast with Suggestions for its Improvement’

http://www.tara.tcd.ie

By the end of the first epidemic over 400 people had died in Belfast and cholera, as did on-going preventative public health provision, passed quickly from public consciousness. Thus, when cholera returned to Ireland in 1848 practically nothing had changed in the way it was fought. However, during this second epidemic, the efforts of Belfast’s new Board of Guardians, the physician and sanitary reformer Dr Andrew Malcolm and additional sanitary powers granted to the new Town Corporation by town improvement legislation arguably prevented a much higher death toll than was experienced elsewhere. The Guardians, for example acted in defiance of the Poor Law Commissioners when they opened the Belfast Workhouse in 1841 with ten beds for the reception of the sick, rapidly increasing this to 100. The Corporation introduced new housing regulations and were granted additional sanitary powers, giving them more authority to require landlords and property owners to remove nuisances and pave streets. However, by 1848 Dr Malcolm reported that there continued to be a ‘lamentable deficiency’ with regard to the removal of offensive remains. As fears of choleras immanent arrival grew the influential Malcolm rose to the fore to guide the municipal authorities. A Sanitary Committee headed by Malcolm and specifically aimed at dealing with cholera in the first instance was formed in 1848. The Committee published and distributed reports, magistrate’s orders were issued for the removal of nuisances, poor families were provided with straw bedding, houses were whitewashed and new sewers were constructed in some parts of the town.

Despite the preparations however, fatalities were almost treble those of 1832. Though Belfast now had two hospitals capable of receiving cholera patients the willingness of the sick to be admitted had declined decidedly. The Committee of the General Hospital attributed the reluctance to ‘prejudices or perhaps the state of apathy and hopelessness which accompanies this severe malady’ and commented that it was a ‘matter of regret, that that the advantages of the hospital were not more generally or duly appreciated by the poor’. By the end of the epidemic 3,538 cases and 1,163 deaths had been recorded but mortality at 33% was again lower than that of other sizable Irish towns. However, in Belfast’s worst affected areas, poverty and deficiencies in sanitation and hygiene had clearly been instrumental in the spread of the disease. And while the town’s municipal authorities had effected much civic enhancement, major sanitary improvements had not been instigated in the areas of the town where they were most required. Nevertheless, some lasting lessons had been learned and when cholera returned again in 1853 and 1866 mortality rates were almost insignificant by comparison.

Nigel Farrell is a third year PhD student based at the University of Ulster Coleraine and is researching cholera and the development of public health in Belfast between 1832 and 1878. The above post is based on his winning entry to the History of Medicine in Ireland Prize competition.

‘Not unlike an evil dream’: a medical student’s account of Spanish flu in the Meath hospital, Dublin by Anne MacLellan

This month's blog post is by Dr Anne MacLellan, Director of Research at the Rotunda Hospital, who discusses the writings of Dorothy Stopford, a Dublin medical student, relating to the Spanish flu in Ireland.

In January 1916, at the age of 26, Dorothy Stopford (1890-1954) entered Trinity College Dublin to study medicine. The 1916 Easter Rising, the Great War, and the Spanish influenza pandemic of 1918-1919, formed the turbulent backdrop to her introduction to medicine. A remarkable series of letters written by Dorothy to Sir Matthew Nathan (Undersecretary for Ireland 1914-1916) during her time as a clinical clerk on the wards in the Meath hospital, Dublin, provide a compelling account of working through the Spanish flu which, hard on the heels of the Great War, claimed the lives of many young Irish people.

The dreaded flu, with its penchant for young lives, brushed against Dorothy in July 1918, following a whirl of exams, when she, herself, had a ‘touch of Spanish flu, cured at night and ignored during the day’. In October 1918, Dorothy, now a third-year medical student, ‘exercised her powers cautiously’ on the wards as she knew she was ‘horribly ignorant and junior’. She could do little other than what the ward sister suggested. ‘I am in her hands and learning a lot. We are packed with influenza cases, mostly DMP [Dublin Metropolitan Police]’. Mortality was high as it was a very violent form of the flu generally ending in pneumonia. However, Dorothy told Sir Matthew that the ‘bug’ had been found and inoculation was being used for curative purposes although it was too late to say with what success.

A monster representing an influenza virus hitting a man over the head as he sits in his armchair. Pen and ink drawing by E. Noble, c. 1918. Courtesy of Wellcome Images. ICV No 16001.

At the end of the month, she suffered from ‘a private tragedy’ when her great friend Cesca Trench died from the flu on 30 October. After a long courtship, Cesca had married Irish volunteer, librarian and biographer Diarmid Coffey on 17 April 1918. Both Diarmid and Cesca were described by Dorothy as ‘very intimate friends’ and she was ‘the most splendid and beautiful creature I had ever known’, wrote Dorothy. Cesca was only ill for three days and ‘went out like a flash, the last person, full of life and vitality, that you could think of dying’.  Cesca’s death was typical in that this flu was more likely to lead to death among young adults than among the usual flu victims – the elderly and the very young.

In November, Dorothy informed Sir Matthew that the ‘general scrimmage of the influenza epidemic which is pretty hot here’ continued. Dorothy worked with two nurses on a landing  in the hospital where there were about 30 ill patients and the sister had been laid low. The ward was full up with policemen and there were a lot of deaths. ‘It was very horrible’, she declared, but things seemed to getting better and most people recovered. Sadly, the sister, who had been ‘particularly nice’ died.

Dorothy was also impressed by her ‘chief’, Professor William Boxwell, who was not only ‘very clever but also very grand and fine, he is up and about night and day and has pulled a lot of people through’. As for her own contribution, she said it was difficult knowing so little and death seemed very terrible. But, she got used to it quickly in the general busyness of ward work and found her feet. The amount of ‘odds and ends’ of doctoring and nursing that she absorbed in two weeks under pressure was ‘rather astonishing and one gains confidence’.

Dorothy Stopford at the Meath Hospital, undated. Photograph courtesy of Dr Ida Milne.

Professor Boxwell was ‘mad on post-mortems’ and Dorothy assisted him with the dead as well as the living. Boxwell tried to get a portion of lung from each flu victim and, at 10 pm, at night Dorothy would bicycle down to the mortuary where, ‘with or without the aid of a night porter’ she carried in about three corpses into the post-mortem room, and ‘stripped them ready and made them tidy again’. She remembered nights when the rain pelted down on the glass roof and she was alone inside trying to get the corpse into its habit and back on the bench. She recalled these details later and did not mention them in her contemporaneous letters – probably in a bid to spare Sir Matthew the horrific details.

On 15 February, 1919, Dorothy Stopford was finding life very exciting, having attained some self-confidence in her powers of healing. ‘I don’t believe at all in women doctors not liking to take responsibility, at least I don’t see why they shouldn’t  but it’s always charged against them.’ It was largely a matter of knowing your work and being careful, she declared, ‘the rest is experience, more than brains, with plenty of self assurance.’ Dorothy Stopford (later Dorothy Price) became a confident, assured doctor with no reluctance to take responsibility. She became a leading international expert on childhood tuberculosis, a public campaigner for the formation of a national anti-tuberculosis league, and the chair of the National BCG Committee.

In March, Dorothy told Sir Matthew that they were having another epidemic, just as bad as the autumn one. ‘Five with pneumonia, the latter proving frequently fatal, and the hospital is once more not unlike an evil dream; still lots recover too.’ She had another public exam looming in a week’s time but was undecided about sitting it as ‘this flu business puts one off book work’.

Author's note: The letters of Dorothy Stopford to Sir Matthew Nathan (MS. Nathan 204, fols.164-291) are held in the Bodliean library in Oxford, England (many are undated so the chronology of the letters is not always clear). The papers of Diarmid Coffey and Cesca Trench are held in the National Library of Ireland, Dublin. The account of post-mortems carried out during the Spanish flu are to be found in the volume Dr Dorothy Price, written by Dorothy’s husband Liam Price, and printed at the University Press, Oxford,  for private circulation, in 1957.

Video

Video of a lecture, 'Victim or Vector? Tubercular Irish Nurses in Britain 1930 to 1960', by Dr. Anne MacLellan, at the workshop, 'Health, Illness and Ethnicity: Migration, Discrimination and Social Dislocation', held at the Centre for the History of Medicine in Ireland, June 2011

Victim or Vector? Tubercular Irish Nurses in Britain 1930 to 1960 from CHOMIreland on Vimeo.

Anne MacLellan is the Director of Research at the Rotunda Hospital, Dublin. She is the winner of the Royal College of Physicians 2012 History of Medicine Research Award and the joint winner of the Ulster University/Centre for the History of Medicine’s History of Medicine in Ireland essay prize, 2011. Anne’s PhD, from the UCD School of History and Archives (2011), was funded by Wellcome Trust. She may be contacted by email at amaclellan1 "at" gmail "dot" com.