The Frustration of Lady Aberdeen in her Crusade against Tuberculosis in Ireland

Abstract

When in his Annual Report for 1905 the Registrar General for Ireland pointed out to the lately arrived Lord Lieutenant, The Earl of Aberdeen, that annually in every 100 deaths in Ireland 16 were victims of tuberculosis, Lady Aberdeen took notice. In March 1907 she founded the WNHA with the clear duty of taking part in the fight against the appalling ravages of that disease, and organised a Tuberculosis Exhibition the following October. And so began a campaign that led to the building of Peamount Sanatorium in county Dublin, the Allan Ryan Hospital at Ringsend, and the Collier Dispensary in the city centre. However, the Irish parliamentarians at Westminster emasculated the Tuberculosis Prevention (Ireland) Act 1908 by ensuring that notification was not made compulsory. Passage of the National Health Insurance Act (1911) necessitated changes that resulted in the Tuberculosis Prevention (Ireland) Act (1913), but the crucial shortcomings of the earlier Act were not rectified: notification was necessary but still not compulsory. Lady Aberdeen recognised this serious flaw she was powerless to correct, and turned to propaganda, editing Sláinte, a monthly magazine founded in January 1909 by the WNHA, and editing a three-volume account of Ireland’s Crusade Against Tuberculosis (1908-1909).

LORD AND LADY ABERDEEN

There’s a divinity that shapes our ends, Rough-hew them how we will.

Hamlet V ii 10.

Four deaths in the space of ten years brought John Campbell Gordon (3:8:1847-7:3:1934) to the peerage.¹ His grandfather George Hamilton Gordon, fourth earl and prime minister died in 1860; his father George John James (fifth) died in 1864; his eldest brother (sixth) was swept overboard while working under an assumed name in the American mercantile marine in 1870; his second brother having died in a rifle accident in 1868, John Campbell was confirmed as seventh earl of Aberdeen in 1872. After education in St. Andrews and Oxford he regularly attended the House of Lords and supported the Liberal Party. In 1886 he spent a courageous if brief spell in the Vice Regal Lodge in the Phoenix Park, Dublin; his departure, precipitated by the defeat of Gladstone’s (1809-1898) First Home Rule Bill, after a friendly lord-lieutenancy was widely regretted. The regret was heightened especially after Salisbury [1830-1903] embarked on ‘resolute government’ and Balfour (1848-1930) the Chief Secretary adopted a policy of ‘repression and reform’. From 1893 to 1898 he was Governor-General of Canada and in 1906, with the Liberals again in power, he returned to Dublin, for the longest term (nine years) in the history of the lieutenancy. King Edward VII (1841-1910) came over in 1907 and George V (1865-1936) in 1911 (visits engraved in the new Royal College of Science, now Government Buildings), the Home Rule Bill became law in 1914, and Aberdeen announced his retirement. He was persuaded to extend his term, and in 1915 when he finally left he was advanced a step in the peerage as Marquess of Aberdeen and Temair (from Teamhair Tara, the royal seat in Meath). On his estates in and around Haddo House in Scotland he improved the welfare of farmers and labourers.

It was during 1886 that the Irish Industries Association attempted to set up cottage and village industries. The restoration of Irish industry was the theme of the Irish International Industrial Exhibition opened on 12 October 1907, the first year of the return of the Aberdeens to Ireland. A City and Town Planning Exhibition opened at the Linenhall Barracks on 15 July 1914, featuring a planning competition for Dublin.

Away back in 1877 Lord Aberdeen had married Ishbel Maria Marjoribanks (14:3:1857-18:4:1939). Ishbel, the youngest daughter of Sir Dudley Coutts Marjoribanks, later Lord Tweedmouth, and Isabella Hogg, was born in London and educated privately (Figure 2).² Her character and ideals, and deeply religious convictions, were moulded by her mother. In Canada with her husband from 1893 to 1898 she became interested in the National Council of Women (which had been founded in Washington in 1888), was elected President in 1893, and thereafter worked strenuously for the social and economic improvement of the status of women. Before leaving Canada she founded the Victoria Order of Nurses in 1898.

Fig 2.

Lady Aberdeen Photographed with Alfie Byrne, perennial Lord Mayor of Dublin, at Peamount Sanatorium in 1937, courtesy of Dr.Tim Healy (p xi)³¹.

Hubert Butler (1900-1991) recalled his Aunt Harriet:

In the days before the War and the 1916 Rising, the more enlightened of the Anglo-Irish were trying desperately to identify themselves with Ireland. ...

The Gaelic League was not politicised in those days and even the British saw nothing against it. When Lady Aberdeen, Ireland’s all but last Vice-Reine, came down to open our local concert hall, she defied the ridicule of the Anglo-Irish neighbours by dressing herself and the ladies of the party in emerald green with Tara brooches. ... She entertained very little in the Vice-Regal lodge, but started a campaign against tuberculosis with no political overtones, and motored all over Ireland trying with some success to introduce village nurses into every community.

Despite all this they were unpopular ... one line [of a poem alleged] that ‘They cut the penny buns in half when Larkin came to tea’. ... The Cuffes and Aunt Florence and my mother all threw themselves into the crusade against tuberculosis (Aunt Harriet believed it was a delusion of the mind) and I think the Bennettsbridge village name was amongst the first in Ireland ³

Castle spongers in Dublin rumoured, on account of the quality of the sandwiches provided at official entertainments, that the Aberdeens were mean, but Denis Johnston (1901-1984) recalled that he was the recipient of a guinea in his charity collection box at the bottom of Grafton Street - dismissed by the sneer that it was a sovereign from a half-sovereign.⁴

THE RISING DEATH RATE

Ishbel the Campaigner did not arise fully formed from the head of Hygeia in 1907, for the rising mortality from consumption in Ireland was unquestionable. The Forty-Second detailed Annual Report of Registrar General for Ireland during 1905 was presented to His Excellency John Campbell Gordon, Earl of Aberdeen, Lord Lieutenant in 1906. In his Introduction Robert E Matheson (1845-1909) wrote:

I venture to invite your Excellency’s special attention to the mortality from tuberculous disease during the year 1905, the number of deaths from all forms of tuberculous disease registered in Ireland during the year was 11,882 representing a rate of 2.71 per 1,000 of the population estimated to the middle of the year, or taking the mortality from the disease in relation to the deaths from all causes registered in 1905, it will be found that in every 100 deaths from the latter, 16 were the victims of tuberculous disease. (p xxi)⁵

The preponderance of deaths from tuberculosis over the other principal causes of death was stressed diagrammatically (facing p xiii)⁵ and it contrasted

the death rate for all forms of tuberculous disease in Ireland for a period of 42 years as compared with the rates for England and Wales and Scotland. From this it would appear that in the year 1864 the rate in England and Wales was 3.3 per 1,000, and that in 1903 it had fallen to 1.7 per 1,000, rising in 1904 to 1.8. In Scotland in 1864 the rate was 3.6 per 1,000, and in 1903 it had declined to 2.1 per 1,000. In Ireland in the year 1864 the rate was 2.4 per 1,000, but in 1904 it had increased to 2.9 per 1,000, falling in the year 1905 - now the subject of review - to 2.7 per 1,000 of the estimated population. (p xiii)⁵

The age distribution of deaths from all forms of tuberculosis in 1903 was also analysed:

In England and Wales the highest rate 3.2 per 1,000 appears in the population under 5 years; this is also the case for Scotland, the rate in the case of Scotland being 3.5 per 1,000 living at that age period; while the rate for deaths for tuberculous disease in the population of Ireland under 5 years was 2.7 per 1,000.

In Ireland the highest death rate occurred amongst those living at the age period 25 to 35 years, nearly 4.5 per 1,000. In England and Wales the rate at this age period was 2.0 per 1,000, and in Scotland it was 2.7 per 1,000, which was the highest rate for adults in that country among the selected age periods. Of the adult age periods, the highest rate in England and Wales appears among those living between the ages of 46 and 55 years, the rate for this age period being 2.4 per 1,000. (p xxiii, and diagram facing this page)⁵

Grimshaw’s (1839-1900) map was revived (facing p xxiv)⁵ - without the meteorological isopleths - (Figure 1).

Fig 1.

Deaths from tuberculosis in Ireland recorded in the Forty-second Annual Report of the Registrar General for Ireland, HMSO (1905).

The maps ... give the death rate per 1,000 of the population from all forms of tuberculosis for each poor law union or superintendent registrar’s district for Ireland for the years 1871-80 and 1905; the deaths occurring from this disease in the lunatic asylums and in some of the principal charitable institutions of persons admitted thereto from Unions other than those in which institutions are situated, having been assigned to the Union areas to which the diseased persons originally belonged. As before stated, the general death rate from all forms of tuberculous disease was 2.71 per 1,000 of the population. It will be seen from the 1905 map that the poor law unions having the least death rate were Tullow 0.92 per 1,000, Lisnaskea 0.93, Borrisokane 1.05, Castletown 1.07, Portumna 1.10. Dunfanaghy 1.14, and Kenmare 1.16; and those having the highest death rate were Londonderry 2.35 per 1,000, Castlederg and Kinsale 3.48 each, Waterford 3.56, Belfast 3.85, Dublin South 4.38, Cork 4.53 and Dublin North 4.70.

Tuberculosis deaths were classified under the following headings: pulmonary tuberculosis (phthisis), tuberculous meningitis, tuberculous peritonitis, tabes mesenterica, lupus, tubercle of other organs, and general tuberculosis (scrofula). (p xxiv)⁵ Between 1870 and 1904 the decennial average death rate from tuberculous meningitis was 710 (355 males, 188 under 5 years and 355 females, 162 under 5 years of age). The aggregate decennial deaths from peritonitis and tabes mesenterica were 437 (205 males, 232 females; 227 under 5 years of age), amounting to 0.10 per 1,000 of the population. (p xxiv)⁵ Ninian M Falkiner (1857-1929), Medical Superintendent of Statistics, was thanked for his valuable assistance, (p xxxii)⁵ and meteorological observations made by J W Moore (1845-1937) were tagged on over thirty one pages. (pp 147-178)⁵

Lady Aberdeen was approached in 1906 by the National Association for the Prevention of Tuberculosis (NAPT) to take part in its programme,⁶ largely ineffectual because of its elitist character. To campaign for better conditions for women, especially in relation to maternity and child welfare, Lady Aberdeen founded the WNHA, which held its inaugural meeting on 13 March 1907. When it was formed:

it was clear that one of the first and foremost duties of that Association would be to take part in the fight against the appalling ravages of tuberculosis in Ireland. .. (p. 1)⁷

The primary object of the Women’s National Health Association is to reach the women of the country and to bring these facts home to them as the guardians of the homes of the country. (p. 6)⁷

On inquiry she found that an itinerant Tuberculosis Exhibition had been found of great value in the United States of America and Germany and elsewhere, so she resolved to form a special committee with a view to organising such an Exhibition. The Exhibition thus formed was opened in the Home Industries Section of the International Exhibition in Dublin from 12 October 1907 to 7 November 1907. When the Exhibition closed in Dublin it moved to Belfast on 7 December, moved to Lisburn 18 December, and on to Lurgan on 11 January 1908.⁸ When the Exhibition closed, the Committee purchased a horse-drawn caravan, named “Eire”, to carry the exhibits round the country. “Eire” was burned at Lifford in February, but by 1 April “Phoenix” replaced it and set off from Fintona to complete its rounds. In April 1909 the Tuberculosis Exhibition came to rest with a final appearance in the Pillar Room of the Rotunda in Dublin.^9,10

THE CRUSADE

Mortality from tuberculosis continued to increase: from all forms in 1904 there were 2.9 deaths per 1000 population.¹ The NAPT, of which a Dublin branch had been founded in 1899, by its lectures and pamphlets awakened the people to the value of sensible precautions. A start had begun to the provision of tuberculosis hospitals and sanatoria thus reducing the number of active cases - the ultimate sources of infection - in circulation. Lady Aberdeen’s Crusade gave added impetus to the modest beginning which had to await the development of chemotherapy in mid-century for a dramatic change to appear.

As a prelude on the eve of the Official Opening of the Tuberculosis Exhibition in Herbert Park, Dublin, in October 1907 Sir William Osler (1849-1919) gave the Keynote Address in the Royal Dublin Society’s Lecture Hall. Lady Aberdeen on a return voyage from Canada met the future Regius Professor at Oxford.¹¹ ‘Osler made use of his powers as an auctioneer in wheedling over £10 out of the passengers’ pockets for Charity Grant for Seamen programmes I had decorated with sundry sketches by order of the captain’.

Outlining the knowledge available for a successful campaign, Osler opened the Crusade on an optimistic note, stressing not only compulsory notification and ‘the proper provision for the care and cure of patients’ but also the necessity for enthusiasm and perseverance.¹² As keynote speaker he was well chosen for he had recently transferred from Johns Hopkins University to Oxford with a reputation that made him the leader of the medical profession. And he was an orator of the front rank.

The Registrar General, Sir Robert Matheson, had attended the London and Paris Congresses as representative of the government, but had retained an affection for Arthur Ransome’s (1834-1922) view that improved sanitation would provide the answer to the problem he had outlined in his Annual Report for 1905.¹³ Fortunately Sir John Byers (1853-1920), professor of midwifery in Queen’s College Belfast, a devotee, summarised Arthur Newsholme’s (1859-1943) more rational explanation of ‘Why tuberculosis is common in Ireland’ - the failure to remove consumptives from their families by providing indoor relief and thus preventing spread of the causative organism without which there could be no tuberculous disease. ¹⁴ Like his academic colleague, Professor Lindsay (1856-1931), professor of medicine,¹⁵Byers denied altogether that the Irish (or some said the Celts) were especially susceptible to tuberculosis.¹⁴ The scale of the problem was addressed by Dr Lawson, medical superintendent of Nordrach-on-Dee Sanatorium, Banchory (named after the sanatorium at Nordrach in the Black Forest - much against the wishes of that institution’s founder, Otto Walther [d. 1919]). After answering the old chestnut that ‘the value of sanatorium treatment has not been proved’, Lawson calculated the Irish requirements at 20,000 beds, compared to the 410 available, and echoed Osler, as did many speakers, on the necessity of compulsory notification.¹⁶

There were those who knew that sanatorium treatment was not the complete or only answer. The Victoria Dispensary set up in Edinburgh in 1887 by Robert Philip (1857-1939) was described in detail by Dr Frank Dunne (1863-1929), physician in charge of the Tuberculosis Hospital, South Dublin Union,¹⁷ (who also provided information on the economical construction of sanatoria) and by the Lady Superintendent at Edinburgh, Miss Guy.¹⁸ The work of the corresponding Calmette dispensaries in Paris was described by Miss Fitzgerald Kenny.¹⁹

Through a special effort of the Gaelic League, Séamus Ó Beirn, of Leenane, was seconded to lecture in Irish on the topics of the Dublin addresses in the Gaeltacht.²⁰

The enviable success of the campaign against tuberculosis in Germany was explained by E J McWeeney (1864-1925), who pointed out that the development of the institutional treatment in that country was not ascribable to Robert Koch (1843-1910, Nobel Prize 1905), the discoverer of the bacillus which placed phthisis firmly among the infectious and preventable diseases.²¹ The consequences of that discovery were not exploited until the great systems of workmen’s insurance were developed towards the year 1886 or 1887. The mainspring of collective action was Clause 18 of the Workmen’s Insurance laws which read:

If an insured person is taken ill in such a way as to render it probable that he may lose his earning power, and thus become entitled to the invalidity pension prescribed by the law, the Insurance Office is empowered to supply in his case whatever course of treatment may seem to it most suitable for preventing such loss of earning power. (p 18)²¹

In 1895 this clause was held to apply to tuberculosis, and the way was thrown open for the enormous development of the sanatorium system that then took place: at the beginning of 1907 there were 87 working class sanatoria with 8,422 beds. {II 16-37}

Simultaneously, consumption dispensaries were also established along the lines of the Philip and Albert Calmette (1863-1933) dispensaries in Scotland and France respectively.(pp 23-25)²¹ Applicants might come of their own accord or be referred by a doctor. If the presence of tuberculosis was established, the patient (at the second visit after 14 days) was asked to bring the other members of the family or household, more especially the children, for examination. By 1907 there were 117 such dispensaries funded by local taxation and voluntary subscription, by insurance societies and by grants from the German Central committee for the Prevention of Tuberculosis.(p 31)²¹

McWeeney distinguished carefully between the dispensaries and the Irish hospital dispensaries and Poor Law dispensaries which provided curative medical care:

The German Tuberculosis Dispensary seeks to track the enemy to his lair - to follow up the disease, discover its hidden hiding places, and cleanse them. It does not seek to cure, but to co-ordinate the already existing curative measures, and focus them on the plague-spots so dragged to the light of day. It seeks out the cases, segregates them into their categories, and puts them on the road to cure, or should this be impossible, robs them of their danger to the family and the community. (pp 31-32)²¹

With the information already available to all, it should be possible, McWeeney argued, ‘to devise a scientific, uniform, and a reasonable plan of campaign against the common enemy - tuberculosis.’(p 33)²¹

Home treatment and the results of Joseph Hershey Pratt’s (1872-1956) “Class” method of treatment in Boston were described, and bovine tuberculosis and the control of milk supplies received the all too necessary attention from a variety of speakers. The message was put in a nutshell by Dr Frank Dunne

An organised and co-ordinated scheme would include:

• i.compulsory notification of disease.
• ii.tuberculosis dispensaries in cities and large towns.
• iii.sanatoria for the treatment of curable cases
• iv.hospital accommodation for the isolation of advanced, highly infectious, and incurable cases.
• v.the proper inspection of food supplies, and in particular the bacteriological examination of milk. (p 57)¹⁷

The lectures were printed and published for mature reflection, and tangible results slowly materialised.²² The Collier Dispensary for the Prevention of Tuberculosis, a solid two-storey building in Charles Street West, Dublin 1, recalls the donation of Peter F Collier (1849-1909) who was born in that street, emigrated to America where he founded Collier’s Magazine and the Saturday Evening Post. The Allan A Ryan Hospital for Consumption (at the Pigeon House on the South Wall in Dublin), another endowment solicited by Lady Aberdeen during a tour of the United States, remained in use until 1955. The WNHA (Figure 3), in collaboration with 14 local authorities (county councils) built a sanatorium at Peamount, Newcastle Co Dublin, with 140 beds, and a smaller one at Rossclare Co Fermanagh. After the enactment of the Tuberculosis Prevention (Ireland) Act in 1908, the Treasury made its first building grants to the Association and the county councils then contracted beds in these and other institutions in preference to building their own. Such a penurious / skinflint approach is explicable in light of the fact that a ViceRegal Commission was established in May 1903 to find ways of reducing cost to taxpayers of supporting the sick and indigent poor - The Report was given to Lord Aberdeen in 1906. The sanatorium at Peamount, Newcastle, Co Dublin was built and opened despite considerable local opposition - on 21 July 1912, the eve of its opening, men from nearby towns and villages demolished one of the pavilions. (p 168)²³

Fig 3.

Certificate of Grand International Prize shared with New York Association in 1908.

They had the support of the Sinn Féin Weekly, which previously echoed the praiseworthy propaganda of the WNHA. (pp 168-9). ²³ Sinn Féin (We Ourselves [Sinn Féin Amháin = ourselves alone]) founded in 1906, it must be remembered, was at that time largely a one-man-band; It was only when its founder Arthur Griffith (1872-1922) was incarcerated with the leaders of the 1916 Rising - in which he took no part - that his party became part of the Republican struggle for independence. Indeed Griffith favoured, as outlined in his Resurrection of Hungary, a dual monarchy with a parliament meeting in Dublin, a schism to be achieved by non-violent means.

Sinn Féin hostility in 1912 must not be seen as a purely Irish problem. It should be recalled in the context of the ‘hostile, or at least apprehensive’ welcome given to the Papworth Village Settlement founded twelve miles outside Cambridge three years later by Pendrill Varrier-Jones:

And not only the ordinary people. A local squire, Colonel Sir Mansfield Baker, led the campaign against a diocesan scheme in 1921 to have the parishes of Papworth St Everard and Papworth St Agnes, a rural mile and a half from each other, amalgamated. “It would empty our church as surely as the plague”, he wrote to the Bishop of Ely. The scheme was abandoned. In both Papworths the villagers kept the lungers at arms length. In 1923 those living along the Papworth-Cambridge bus route lobbied the local bus company not to stop the buses near the village settlement, at least on the early morning school-run. That wish too was granted. (p 312)²⁴

It is a truth universally acknowledged that all politics is local - but some is less local than we care to admit.

The ViceReine used her influence with the Viceroy and Chief Secretary for Ireland to meet a deputation with a view to introducing legislation. On 29 November 1907, a deputation of medical corporations and societies and other associations working against tuberculosis was received by the Lord Lieutenant, Mr Birrell (1850-1933), the Chief Secretary, and Mr Russell, Vice-President of the Department of Agriculture. (p 127)²⁵

The Countess of Aberdeen introduced the focus points to be presented by members of the bodies:

• (1)That special legislation should be introduced without delay with the object of making it compulsory that all cases of tuberculosis should be notified, taking care at the same time to protect consumptive patients from any undue interference with their liberty.
• (2)That the adoption of some stringent and uniform measures for the regulation of milk and food supplies is urgently required.
• (3)That County Councils in Ireland should be enabled to erect and maintain such hospitals, sanatoria, and dispensaries for the treatment of consumptives as they think fit.
• (4)That there is urgent necessity for a system of medical inspection of schools and school children. (p 127)²⁵

The Countess then asked individual delegates to speak on the four points, seriatim.

In dealing with compulsory notification Dr Joseph M Redmond (1853-1921), president of the Royal College of Physicians, stressed that ‘every precaution should be taken so that the liberty of the poor patient suffering from tuberculosis should not in any way be interfered with, and also that every safeguard should be used in order to prevent the confidential relations which exist between the medical attendant and his patient from being in any way strained’. Sir Henry Swanzy (1844-1913), President of the Royal College of Surgeons, also urged that notification be compulsory ‘to enable us to discover all the cases of pulmonary tuberculosis if it be properly applied, but warned that ‘with regard to the public, no very harsh measures must be attempted’, and, further, he realised that ‘compulsory notification ... will be much in the hands of the medical profession, ... and it is of the utmost importance that their good will should be secured in order that this recommendation may be worked with success’. (pp 130-132)²⁵

The Chief Secretary, ‘to whom the work of putting through any Parliamentary measure will be allotted’, replied by saying that he recognised the ‘first rank’ importance of notification, quoting the Paris October 1905 conclusion ‘that it is desirable that it should be the general practice to notify all cases of advanced tuberculosis’, but concluded (with due regard to human nature and medical etiquette) ‘We must recognise the necessity of notification, but we will take into consideration the hints you have given us so as to avoid imposing penalties or creating a scare in the public mind, which would destroy the very object we have in view’. (pp 146-150)²⁵

Was Lady Aberdeen aware of the subtle undercurrent that foreshadowed later legislation? Compulsion, it has to be said, has lost none of its difficulties.

Infection by ingestion as well as inhalation was not neglected. In his lecture on ‘Control of Milk Supplies and other Conditions affecting Tuberculosis’ A K Chalmers (1856-1942), Medical Officer of Health of Glasgow, pointed out that legislation controlling milk supplies was only indirectly useful with regard to spread of that disease.²⁶ Dairies’ Orders under Section 34 of Contagious Diseases (Animals) Act of 1878 were drafted not with the object of protecting mankind from disease, but of controlling the spread of infections (cattle plague, foot and mouth disease, pleuro-pneumonia, and - later - anthrax) among domestic herds. It was not until 1899 that Amending Orders brought tuberculosis of the udder into the list. The clauses of various Public Health Acts applied in their original conception to epidemic diseases such as scarlatina (scarlet fever) and enteric (typhoid) fever. And the intentions behind the Sale of Food and Drugs Act (1875) concerning milk supplies were designed to deal with the adulteration and watering of milk.²⁶ A footnote on page 10 of Chalmers’ lecture pointed out that a start was made with the specific structural provision in the Dairies, Cowsheds, and Milk-Shops Order issued in February 1908, applicable throughout the districts of all sanitary authorities in Ireland after 1 May 1909.²⁶

To show the way forward Professor Albert E Mettam (1866-1917), first Principal of the Royal Veterinary College Dublin in reviewing ‘Tuberculosis in Lower Animals’ drew attention to the fact that already in Schleswig-Holstein, the province annexed by Germany in 1864, all cattle affected with tuberculosis (in whatever site) were destroyed, and compensation allowed.²⁷

Professor Thomas Carroll (1887-1918) showed how unfavourably Ireland, and to a lesser extent Scotland and England, compared with Denmark, when death-rates between the years 1875 and 1905 were examined,(pp 31-37)¹⁸ and he proffered the reason

By an Act of 1893, the movement of animals evidently suffering from tuberculosis to fairs, markets, shows, strange stables, etc., is prohibited. It is not allowed to sell or offer for sale the meat of such animals except after it has been examined by a qualified veterinary surgeon, and is certified by him as being fit for use ... The regulations as to the sale of milk in Denmark are particularly rigid. By an Act of 5 February 1904 ... it is required that all dairy milk and buttermilk shall be heated at 80°C ... all cream churned for butter-making must be heated to 80°C. No milk can be imported unless it is heated. ... We can learn a lesson from Denmark that, even in public health, co-operation may be a great aid. (p 35)²⁸

But even the Danish farmers so eulogised by Professor Carroll,²⁸ when they were preparing milk for their own use, were remiss or less than careful in Pasteurisation, for there was a higher incidence of bovine infection in agricultural as against urban areas as late as 1935.²⁹

As among people, however, among nations and governments there are slow learners, and the ViceRegal Commission on the Irish Milk Supply which made its Final Report (of the Irish Milk Commission) in 1911 did not materially improve the quality in bacteriological terms.³⁰ However, as always, Lady Aberdeen led by example and paid for land acquired to enlarge the farm attached to Peamount Sanatorium to supply safe milk and fresh food for the patients, some of whom initially helped in the farmwork. (pp 83-87)³¹ The finances of the model farm with pedigree milch herds were separate from those of the sanatorium, and at various times were boosted by sale of tobacco and barley crops.(pp 130-136)²¹ Peamount Industries 1930-40, watched over by P J Varrier Jones (1883-1941), was a separate development (pp 92, 96-101)³¹

In 1925 over 8 per cent of milk samples in Dublin contained live tubercle bacilli; ‘the powerful farmers’ lobby saw to it that the Free State Government regularly shelved Clean Milk Bills, let alone compulsory pasteurisation’.(p 240 n 20)²⁴ In a usually impeccably referenced text, Thomas Dormandy does not provide a source for this statement but directs the reader to Chapter 29, where it merely reappears in paraphrasis in a footnote (p 332 n 9)²⁴.

PARLIAMENT AND PEOPLE

On Wednesday 3 June 1908 the Tuberculosis Prevention (Ireland) Bill:

To prevent the spread and provide for the treatment of Tuberculosis, and for other purposes connected therewith,

was presented by Mr Birrell; supported by the Attorney-General for Ireland; to be read a second time upon Wednesday next, and to be printed.³²

Hansard noted that the Report from Standing Committee A .C. was lain on the Table of the House on 4 November, to be printed, as well as the Standing Committee’s Minutes.³³ On 10 November Mr Ginnell wished to ask Mr Birrell to consider the advisability of dropping the Tuberculosis Bill in favour of the promised Land Bill.³⁴ A week later Capt Craig (first Viscount Craigavon 1871-1940, Figure 4), careful Ulster housekeeper that he was, asked the Prime Minister whether it was proposed to extend the scope of the Bill to England and Scotland lest consumptive poor persons there might be sent to Ireland where they would become a burden on the rates; Prime Minister Asquith (1852-1928) answered that ‘The inquiry opens up a large question with regard to the Law of Settlement’.³⁵ To Mr J P Farrell’s (1865-1921) request on 23 November that words be inserted ‘which will give individuals and families notified a right of appeal ... before removal from their houses’, Birrell was able to respond that ‘the member is under a misapprehension in thinking that power is sought under the Bill for the compulsory removal from their homes of persons suffering from tuberculosis’.³⁶

Fig 4.

Statue of Sir James Craig in the Hall of Parliament Buildings, Stormont.

The Bill as amended by standing Committee A came up for its Third Reading on 16 December 1908. Tom Kettle (1880-1916, Figure 5)

had no desire to be ungracious, but speaking with the sincerity and seriousness of a person two members of whose own immediate family history had died from tuberculosis, he was bound to say that the Bill was going to scare everybody and cure nobody in Ireland. He believed that the medical men supporting the Bill had made pretensions to knowledge they did not possess; and as the noble Lord [Balcarres] had said, the disease, if it was to be compulsorily notifiable, ought to be notified in the early stages. He had in his own experience, had the perfectly definite statement of a leading medical specialist to the effect that there might be no symptoms of tuberculosis in a person and yet he might be dead and buried four months afterwards. If they were going to make the notification compulsory, if they were going to make a physiological black list in Ireland, if they were going to make an attack on family life, and if they were going to make those afflicted with the disease to be looked upon as lepers, then the State ought to have done something to help them; but it had done nothing to help by contributing funds for the establishment of sanatoria or the making of provision for the treatment of tuberculous patients. Whatever satisfaction the Bill might give the Vice Regal Lodge in Dublin, he did not believe it was going to cure a single person affected with tuberculosis . The problem was rather one of bad houses, under feeding and general depression than anything else. Certain members were exalting the Bill as one of first-class importance, and he felt bound to make these remarks.³⁷

Fig 5.

Bust of Tom Kettle in St. Stephen’s Green, Dublin.

Before Mr Kettle got to his feet another hardheaded Unionist, Mr Barrie, warned that ‘there were county councils in Ireland who were not so anxious to incur additional taxation with a view to preventing this terrible scourge’.³⁸ Like Craig he was more honest than dissenting Home Rulers too conscious of ratepayers’ voting power. If under feeding and poor housing were so important how did the disease kill any of the well-to-do Kettle farmers? Moreover, the word ‘Prevention’ in the title gave the Bill no pretensions to cure a single person.

Kettle was invidious in his selective attitude to the medical profession: those supporting the Bill were misguided fools, but a specialist friend was infallibly correct. Selective quotation from his emotional outburst (p. 169) ²³ scarcely does justice to the misapprehension that brought him to annihilation at Ginchy on 11 July 1916 believing that he was soldiering on behalf of

a dream, born in a herdsman’s shed.

On 17 December the Bill was brought from the Commons to the House of Lords. Tributes were paid to Lady Aberdeen, even though Lord Killanin (1867-1927) opined that ‘the measures will accomplish very little’ because ‘healthy young people are emigrating’ in response to Yankee advertisements in newspapers.³⁹ Two days later the minor amendments proposed by their lordships were considered forthwith, and agreed to. Among the many Bills receiving the Royal Assent on 21 December 1908 were the Tuberculosis Prevention (Ireland) Act and ‘an Act establishing two universities in Ireland (Queen’s University Belfast and the National University) to take ‘an honourable part in the future education of the country’.⁴⁰

The Tuberculosis Prevention (Ireland) Act was reprinted in Volume III of Lady Aberdeen’s Crusade,²⁶

Part I Notification and Disinfection	Part III Sanitary Provisions
Part II Hospitals and Dispensaries	Part IV General

I 1 - (1) If any medical practitioner attending on any person, within any district to which this Part of the Act extends, becomes aware that that person is suffering in any prescribed circumstances from tuberculosis of any prescribed form, or any prescribed stage, the medical practitioner shall within seven days after he becomes aware of the fact send to the medical officer of health a certificate in the prescribed form and containing the prescribed information.

3 - (1) This part of this Act shall extend to any urban or rural sanitary district in Ireland after the adoption thereof.

II 4 - (1) A county council may, if they think fit, provide hospitals and dispensaries for the treatment of inhabitants of their county suffering from tuberculosis, and for that purpose may

• (a)themselves establish and maintain such hospitals or dispensaries; or
• (b)enter into an agreement with any person having the management of any hospital or dispensary for the reception, maintenance, and treatment in the hospital or for treatment in the dispensary, as the case may be, of any such inhabitants of their county as aforesaid.²⁶

In the Bill as originally drafted the duty of prescribing the forms and stages of tuberculosis to which, and the circumstances in which, notification of the disease should apply was entrusted to the Local Government Board alone. When the Bill reappeared in the Commons five months later in November 1908, as amended by Standing Committee A, subclause 2 of clause 1 had been altered so that the Irish Branch Council of the General Medical Council would serve as an Advisory Committee to the Irish Local Government Board. The Irish Branch Council was willing to act but pointed out to the Government that it had no funds at its disposal to defray the necessary expenses. As it transpired, without consulting the two incumbents, the Presidents of the two Royal Colleges in Dublin were constituted an “Advisory Committee” to the Local Government Board.⁴¹

On 3 June 1909, The Local Government Board issued an “Order” prescribing the forms and stages of tuberculosis to which, and the circumstances in which, section I of the Tuberculosis Prevention (Ireland) Act should apply. Notification was not ‘indiscriminate’; under Section I it applied to any stage of “Tuberculosis of the Lung” at which the sputum discharged by the patient made him liable to communicate the disease to other persons, but only in very restricted circumstance: where the person suffering (from the disease)

• (1)Habitually sleeps or works in the same room as any other person or person not so suffering, or
• (2)Is employed or engaged in handling, preparing, or distributing milk, meat, or any other article of human food intended for sale to the public.⁴¹

Limitations were inevitably a feature of contentious legislation; it is easy to see now how discrimination could also gain silent entry.

The Act came into force on 1 July 1909, but only two sanatoria were built, at Streamhill, Buttevant Co Cork and at Crooksling, Co Dublin, the latter - closed during World War I - an incomplete copy of Nordrach.

But Section 3 - (1) left the adoption open, and the permissive rather than the compulsory nature of notification was a serious failure attributable to rhetoric and rationalisation of the Irish Parliamentary Party at Westminster. It has to be said, however, that Bulstrode’s Supplement in continuation of the Report of the Medical Officer to the Local Government Board for 1905-06 provided suitable ammunition, and Arthur Newsholme may have quietly advised against compulsion, favouring voluntary notification for Britain as a whole.¹

Sharing the Grand International Prize (Figure 2), for the most effective work accomplished since 1904 by a voluntary association, with New York, was small compensation when it was awarded in Washington at the International Congress (26 September to 3 October 1908) attended by A Newsholme, J P McDougall and T J Stafford who furnished a valuable report which stressed once again that compulsory notification was ‘an indispensable preliminary to effective and complete preventive measures against tuberculosis’.²⁶ From its first number in January 1909, Lady Aberdeen edited Sláinte, the magazine of the WNHA, which, as well as promoting a healthy life-style, portrayed sanatorium treatment in an understandably favourable light.⁴²

National Health Insurance

A system of compulsory national health insurance for large numbers of the workforce was introduced in Germany in 1883.⁴³ Its architect, Otto von Bismarck (1815-1898), would have wished to introduce an exclusively state-funded scheme but contributions came in varying proportions from the workers and employers as well. Major industries with numerous employees were the main contributors, so that a large segment of the workforce in agriculture and poorly-paid jobs was ignored in a predominantly urban scheme, not entirely a disaster since tuberculosis is an urban rather than a rural disease.

Influenced no doubt by the German experience, Lloyd George (1863-1945) - when he was Liberal Chancellor of the Exchequer - successfully steered his National Health Insurance Act through parliament in 1911, and the Irish Insurance Commission established in 1912 was in satisfactory operation by 1913.⁴⁴ In 1912 the Treasury set up a Departmental Committee on Tuberculosis with T J Stafford of the Irish Local Government Board and Dr Maguire of the Irish Insurance Commission under the chairmanship of Waldorf Astor (1879-1952). With Arthur Newsholme now medical officer to the Local Government Board, it is no surprise to find the provision of sanatoria and tuberculosis dispensaries given top priority, and the appointment of county medical officers of health and the provision of school medical services strongly recommended.⁴⁵ In a codicil to the National Health Insurance Act the Medical Research Committee (later Council) was created with a budget to fund tuberculosis research; but the failure of inspiration in that regard prompted the members to spread their nets elsewhere.

Lloyd George, in gladly accepting the Report, committed the government to paying county and borough councils half of the cost of treating non-insured persons. However, the compulsory notification of tuberculosis, which the Local Government Board recognised as crucial to the success of the scheme, yet again met with Home Ruler opposition and did not apply in Ireland. But at least a tuberculosis dispensary service was inaugurated, and by March 1913, 25 councils had appointed tuberculosis officers, and an additional three were appointed the following year.⁴¹ Few, if any, new posts {jobs for the boys to stem medical emigration (p 168)²³- a drop in the ocean} were subsequently established. But building suitable tuberculosis dispensaries was another matter, the education programmes of the Itinerant Exhibition and the WNHA failed to convince many that such dispensaries were not foci of infection for the spread of the disease. The Tuberculosis Prevention (Ireland) Act 1913 was introduced to make the necessary changes brought about by the National Health Insurance Act of 1911, but unfortunately none of the shortcomings of the 1908 Act were rectified by this new legislation.⁴¹ The responsibility for providing sanatoria was shifted from Joint Hospital Boards and Boards of Guardians on to county councils. Dublin Corporation took over the Collier Dispensary in Charles Street and the Allan Ryan Hospital at the Pigeon House, Ringsend, and Belfast Corporation took over Whiteabbey Sanatorium in 1914. Sanatoria were built at Armagh, Dungannon, Clonmahon, Roscrea and Monaghan, and dispensaries sprang up at Tralee and Killarney in Kerry, in Tipperary and, on behalf of Dublin County Council beside the Meath Hospital and Dublin County Infirmary (to give that hospital its full title) in the city.⁴¹ In any event the political consensus achieved through Lady Aberdeen’s patience and organisational skills between “’constructive’ unionists and parliamentary nationalists … in the campaign against tuberculosis was beginning to disintegrate” before she sailed for home with the Viceroy in 1915 ⁴⁶ , frustrated by the lack of progress in Parliament in the five years after the 1908 Act that failed to introduce compulsion, a key component of preventive legislation.

In reality the seeds of fiscal trouble were already sown. Parsimonious Irish politicians had already covered themselves with ignominy when they relentlessly ensured that the Education (Provision of Meals) Act, 1906^47,48 enabling local authorities – at their discretion - to provide meals for school children, for fully a decade did not apply in Ireland. (p98)⁴⁹ A celebratory breakfast in April 1900 in the Phoenix Park for the visit of ‘the Famine Queen’ was all that had been possible within their little reign.(p 63)⁴⁹ The following June the Patriot Children’s Treat Committee feasted 20,000 Dublin children in Clonturk Park, Drumcondra, and from the Committee grew Inghinidhe na hÉireann (Daughters of Ireland) presided over by Maud Gonne (1866-1953) even when she was away in Paris.(p 63)⁴⁹. In October 1910, stimulated by their President, Inghinidhe began supplying dinners to the children of St Audoen’s parish (with the blessing of Canon Kavanagh) and nearby John’s Lane school.(p 99)²⁰ Although Maud originally assumed that ‘starvation of little children working hard with their brains’ led to mental ill health, by December 1910 she could write to the Irish-American lawyer, John Quinn (p.97)²¹

The number of deaths from consumption in Ireland – the more I looked into the question – the more shocking I found the neglect of the children. It is one of the most vital national questions. If we are to get free and keep free, we must keep up the strength of the race.

Quinn sent £25, and meals were also provided from February 1911 in Ringsend school.(p 99)⁴⁹ With the help of James Connolly (1870-1916) and the Irish Trades Council, Inghinidhe arranged meetings in the Mansion House in November 1910 and November 1912, but their protests failed to convince Dublin Corporation that meals should be provided in the city schools. In December 1911 Maud Gonne’s philippic appeared:

A great wrong is being done in our midst. Hundreds of child lives are being sacrificed; thousands of Irish boys and girls are being condemned to life-long physical suffering and mental insufficiency by schoolday starvation.

Under pain of imprisonment Irish parents are by English law obliged to send their children to school, and from 9:30 to 3 o’clock the children are obliged to remain in school.

No provision is made for feeding the children thus taken into custody.⁵⁰

And she went on to cite the needs of growing children as recommended by medical specialists, and warned Irish MPs that ‘Revolutions have been made for less valid causes’. The 1906 Act permitted local authorities to strike a halfpenny rate, and 4 pence a week per child sufficed in St Audoen’s.⁵¹ A year later an essay by Dr Stephen Walsh was no more successful.²³ The city fathers pleaded that they could not strike a rate without permission from Westminster until the Act was extended to Ireland; after gelded Home Rule was conferred in August, extension was finally achieved in September 1914. (p100)⁴⁹

Lest it be said that this portrayal of pennypinching polititians is unduly biased, let the earlier words of Mr Birrell, when he was President of the Board of Education, speak for most if not all of his colleagues:

… Charity was not to be sneezed at, but it required to be steady and well-organised, otherwise it was apt to be sporadic, fanciful, and fitful. He hoped, too, that local education authorities would fully consider whether they could not properly utilise voluntary agencies and organise and receive contributions from them in aid of the rate or any other relief they might think it necessary to establish. He did not suppose for a moment that any popularly-elected body, with ratepayers behind it, would be anxious to increase the burden of the rates, or that they would desire to discourage the assistance of charitable persons in the community. He thought it was not much use saying that this question was part of a far greater question – everything was part of a greater question. Everything was part and parcel of education. … ⁵²

and indeed of the prevention of tuberculosis. But Mr Birrell cannot be pilloried exclusively, for when the medical deputation led by Lady Aberdeen met the Lord Lieutenant on the 29^th October 1907, the Presidents of the Royal Colleges in Ireland voiced the likely difficulty in persuading physicians and surgeons to notify cases. They hinted broadly to the Chief Secretary that he should ‘avoid imposing penalties or creating a scare’²⁵.

The authors have no conflict of interest