by Ian Miller, Ulster University
No matter how apparently flourishing a city may be, its merchants thriving and its artisans well employed, it cannot be said to be happy or prosperous when sickness is prevalent; when its deaths-rate is excessive; when, in fact, its very prosperity is founded on the life blood of its people…we have not only the ignorance and carelessness of the poor, but the apathy of the wealthier classes, with which to contend.[1]
Henry Whitaker, 4 January 1893.
The 1890s began portentously. In 1891, influenza, the ‘dread scourge’, visited Belfast. Out of 6,357 deaths registered in the city that year, 1,784 were caused by respiratory disease, mostly phthisis (or pulmonary tuberculosis). ‘I am afraid that little can be done to prevent this terrible loss of life’, regretted Henry Whitaker, Belfast’s Medical Officer of Health. The city was badly positioned just above water level. New parts of the city had been built on reclaimed land and mud, but Belfast’s atmosphere was constantly moist. Unhealthy mill working conditions mitigated the geographical benefits of fresh air, open streets and comparatively spacious houses. Whitaker considered Ballymacarett, the area of East Belfast set in the shadows of the Harland and Wolff crane, a lost cause. Resting almost at sea level, flood prevention and effective sewerage was proving difficult.[2]
Whitaker’s appointment had been viewed sceptically. Some believed it had arisen from Whitaker’s close connections to Belfast Corporation rather than any notable proficiency in public health or medicine. Many Corporation members were nonchalant about concerns such as the city’s sanitation. When the Corporation met in 1896, Alderman Graham announced that Belfast’s health was ‘perfectly satisfactory’. He even expressed pride in Belfast being among the healthiest manufacturing cities in the United Kingdom. Similarly, Councillor Woodside argued that ‘he did not believe that Belfast was the rotten hotbed of filth that many people would lead them to believe’.[3] These statements perhaps reveal more about the Corporation’s reluctance to provide funding for public health. In reality, Belfast’s annual death rate was then higher than London’s, even though the city was less polluted and congested.[4]
In autumn 1896, the Corporation’s complacency was shattered when the British Medical Journal (BMJ) published a damning accounts of Belfast’s sanitary condition. The journal revealed that in late September, Dublin’s death rate was 15.5, but Belfast’s was 24.3. Worse still, this shockingly high figure had been the norm for the past three decades at least, grumbled the BMJ.[5] The editors asked how could it be: ‘That a new city with all the advantages that great wealth, an equable climate, and a comparatively admirable situation can bring should always be the home of typhoid, and should have a death rate from consumption [tuberculosis] twice as high as an ordinary English or Scottish town’.[6] Dublin-based newspaper, Freeman’s Journal, reported that Belfast’s citizens had long been living in a ‘fool’s paradise’ regarding its municipal government’s performance.[7]
Historians (including Stuart Irwin whose research can be watched here) have commented upon the Corporation’s disinterest in financing effective urban public health measures.[8] Throughout the century, many British cities had cleaned or removed their cesspools and privies, but the costs of hygienically removing human waste was considerable.[9] In Belfast, traditional open privies, located outside, were still common, but these were harder to empty and clean compared to the newer flushing toilets.[10] Until 1893, sewers discharged directly into the River Lagan. A new sewer system was introduced which sent crude sewage two miles seaward into Belfast Lough. However, reportedly ‘the wooden shoot was leaky and always breaking due to a slow rate of flow…since 1897…sewage has been largely discharged, through bursts and various leaks in the shoot, over the West Bank slob lands’.[11] Poor quality housing was another persistent issue.It was common practice to dump refuse on ground intended for houses to be built upon, an unhygienic tradition which nationalist MP Joseph Devlin thought the Corporation encouraged.[12]
Image: Birth and Death Rates per 1000, Belfast, 1880-1909. Report of the Medical Officer of Health, Belfast County Borough (1909). Wellcome Collection. Attribution 4.0 International (CC BY 4.0).
Tracking and Tracing
Evidently, Belfast, now a city, was still a highly pathogenic environment with considerable risk of infection. However, its main problem was local political disinterest. Unlike most other cities, Belfast lacked a notification system for ‘tracking and tracing’ infections. Since the 1870s, towns and cities across Britain and Ireland had introduced disease notification systems. Upon being notified of an outbreak, public health officials compulsorily (and legally) removed patients to hospitals and shut down insanitary businesses. These local governments saw long-term benefits in funding public health.[13] Belfast remained without such a system, meaning that disease continued to spread unchecked. One angry correspondent to the local press protested in 1893:
The milkman who supplies your milk, the butcher who provides you with meat, the tailor who makes your clothes, may all have smallpox raging in their houses and our public health committee and its officers be as ignorant of this fact as your unfortunate self. All of this could be remedied by a simple vote of the Belfast Corporation.[14]
It was as late as 1897 that the Infectious Diseases Act came into force in Belfast. The positive effects were immediately visible. When two smallpox cases appeared that year, the infection spread no further.[15] However, a new dilemma emerged. Once an infected person had been identified, hospitalisation was preferable. But, also unlike other major cities, Belfast lacked a dedicated infectious disease hospital.
An Infectious Disease Hospital
Belfast’s two main hospitals were the Royal Victoria (perceived as the Protestant hospital) and the Mater Infirmorum (its Catholic equivalent).[16] As far away as the House of Commons, debates raged about the Corporation, driven by ‘sectarian bitterness’, being unwilling to fund the expansion of the Mater Infirmorum (opened in 1900) with the excuse that Protestant ratepayers were being ‘duped’ into funding a Catholic hospital.[17] However, another place existed boasting a range of medical facilities: the workhouse (then situated on Lisburn Road). Throughout the 18th and 19th centuries, workhouse medicine was central to the medical experiences of the poor. Workhouses often had more beds than charitable hospitals.[18]
Despite boasting efficient medical facilities, workhouses were stigmatised institutions avoided at all costs by the labouring classes. Becoming a pauper symbolised social failure. Workhouse conditions were notoriously grim. The threat of the pauper grave loomed. In practice, hospital provision for the infected was used primarily by workhouse paupers. Widespread reluctance to accept workhouse hospital treatment meant that infected individuals died or recovered at home, often in the insanitary conditions which had exposed them to infection in the first place. The infected remained at large in the community, free to roam around the streets and potentially contaminate others. A stigma-free infectious disease hospital managed by the Corporation, not the Poor Law Guardians, promised to resolve this situation.[19]
Given the city’s stubbornly high death rates, Belfast desperately needed an infectious disease hospital. Catholics and Protestants alike fell sick. A proposed new hospital for infectious disease was intended to benefit both communities. In 1891, a Committee recommended that the Council build a new fifty-bed hospital for infectious disease, with separate disinfecting and washing departments.[20] However, the hospital’s construction was delayed for years due to ongoing dispute about its preferred location. In 1897, a Local Government Board Inquiry suggested that part of the Purdysburn estate, already home to an asylum, was suitable. The Asylum Board of Governors initially raised no objections, but declared a legal difficulty. The title deeds were missing![21] Presumably, these were found at some point, but the dispute nonetheless continued. At ongoing meetings about the Corporation’s proposals, only a handful of doctors from the Ulster Medical Society raised their hands in favour of the Purdysburn proposal.[22]
Instead, the doctors wanted the hospital built in Belfast city centre. Their adamance on this matter damaged their local reputation. Many suspected that the doctors simply didn’t want the inconvenience of travelling out of town to work. One letter sent to the Belfast Newsletter about the doctor’s stubbornness read:
It is wonderful the unanimity doctors display in wishing to have the new infectious disease hospital placed in the midst of a teeming population, so that they and friends of the patients may find it convenient to make a rabbit burrow of the buildings. Not a word about isolation to stamp out disease…doctors and other visitors coming from the hospital would carry with them germs of disease into trams, trains and public conveyances of all sorts, besides brushing past pedestrians in crowded thoroughfares.[23]
Another correspondent questioned the logic of housing patients in the city centre when they could be benefitting from fresh country air.[24] Sunlight and air were both thought to kill tuberculosis bacteria and potentially cure patients.[25] Purdysburn also benefitted from having few surrounding dwellings or businesses.[26] Thanks to road and transport improvements, and the recent development of ‘telephonic communication’, other industrial cities had built new hospitals on the outskirts. There seemed little reason, other than the doctors’ commute, for Belfast not to follow suit.[27]
The Purdysburn Fever Hospital eventually opened its doors in 1906 with 168 beds.[28] However, it took some time to convince potential patients that a hospital could be curative. Many working-class families still viewed hospitals suspiciously as grotesque sites of experimentation and dissection in which the caring atmosphere of being sick at home was replaced with a strict paternalism. As late as 1913, reports still surfaced of local doctors avoiding notifying public health authorities of scarlet fever outbreaks out of sympathy with their patients’ concerns and wishes about the hospital.[29]
The “Spotted Fever” Epidemic of 1907
In 1907, disaster struck. An epidemic of cerebrospinal meningitis arrived, colloquially referred as ‘spotted fever’.[30] Spotted fever was its most deadly between January and April when the virus rapidly spread. Between 1904 and 1905, spotted fever killed thousands of children in New York.[31] In 1906, it became rife in Glasgow.[32] At its peak, an estimated thirty people per week died of meningitis in that city. In the opening months of 1907, spotted fever struck Belfast ferociously. That year, 548 people died from spotted fever out of a total of 725 known serious infections.[33]
The time between the onset of symptoms and painful death could be short. On 12 April, a man named Mr Spence was suddenly taken ill while walking along Kimberley Street in affluent South Belfast. He died while being transported home.[34] On the very same day, newspapers reported the sudden deaths of Nurse McDonnell, who had contracted the disease from a patient, and Constable Egan, described as ‘a fine specimen of robust athletic manhood’. Adding to the anxious feeling across the city, the health authorities refused to release daily statistics on the epidemic’s progress.[35]
Image: Kernig’s Sign. William Osler, ‘The Cavendish Lecture on the Etiology and Diagnosis of Cerebro-Spinal Fever’, British Medical Journal, i:2008 (24 June 2009), p. 1521.
Spotted fever decimated families. In April, the virus arrived at the home of John MacKay, a 36-year old Scottish man employed by Dunville’s Distillery as a foreman who lived in the area now known as the Village (Donegall Road). On 8 April, John’s wife died from meningitis. John slipped into intense mental depression. He was now left behind to care for five children, the eldest of whom, a 13-year-old girl, then died from meningitis too. On Saturday 20 April, John asked his 11-year-old son to look after the remaining children while he got dressed. The boy visited his neighbour, Mrs Turner, who was nursing and cooking for the children. Meanwhile, John hanged himself from his bedpost. Two days later, another of his daughters passed away, also from meningitis. Mr Dunville promised to pay all funeral expenses and provide for the few children left behind until relatives could look after them, describing the case as one of the saddest he had ever heard.[36]
Unlike many other infections, spotted fever was not confined largely to the impoverished. A contributor to the Daily Mirror commented on one of Belfast’s victims being an Oxford undergraduate and clergyman’s son. Germs (or a virus, more precisely) might well have directly caused his death but, in the author’s words, ‘It is the product of dirt. It is born in slums. It is the direct result of our allowing a large number of our population to herd together in places where we should be ashamed to keep our dogs’. The anonymous author continued his warning to the affluent classes by writing:
Suddenly the Comfortable Person begins to feel a pain in his head. He turns violently sick. He is put to bed and cries out in agony if he is touched, so sensitive has his skin become. In a few hours, he is dead. Killed by the slums he was so anxious not to disturb! To pull them down would have cost him perhaps an extra farthing on his rates. Now he will never have to pay rates any more.[37]
Spotted fever was not the most contagious of diseases, but its mortality rate was alarmingly high if the virus passed into the spinal column or brain membranes, and if symptoms presented. Children died in large numbers. A seemingly healthy child might be seized suddenly with fever, vomiting, excruciating head and neck pains, and a sensitivity to both light and touch. One common symptom was known as Kernig’s sign (see image above). This occurred if the whole spinal column was infected. The entire body, now paralysed, curved backwards in a frightful half-circle, and remained in that position, usually until death finally arrived. A shrill, high-pitched cry was another serious and unusual symptom. Death could occur in hours or illness could be prolonged for weeks, even months. Some victims slipped into a coma; not all of them awoke. The few who survived could face a lifetime of blindness, deafness, paralysis, mutism or impaired memory.[38] Spotted fever’s cause was viral, but the medical profession was yet to fully understand the differentiation between bacteria and viruses.[39]
For months, the city lived in fear. Large placards were posted in prominent places outlining the penalties now in place for infringing public health regulations. Anyone who held a wake for a spotted fever victim faced a £5 penalty. Parents were fined if they knowingly sent an infected child to school.[40] Mothers demanded that schools shut until the disease had been stamped out. Regardless, many kept their children off school.[41] Confusion ensued about whether teachers would still be paid if no-one attended.[42]
Image: Children and adults in back street of Crozier’s Row, 1912. © National Museums NI.
A Damning Health Report
Enough was enough. The spotted fever epidemic made visible the human cost of refusing to finance public health and sanitation. In 1907, the Local Government Board of Ireland instructed a Health Commission to visit the city to investigate why so many preventable deaths were occurring. The Commission visited Belfast’s factories, workshops and hospitals, and inspected housing conditions, sanitary arrangements, refuse depots, tipping grounds, markets, water supplies and the abattoir, all with the help of the recently formed Citizens Health Committee.
In its unfavourable 192-page report, published the following year, the Commission criticised ongoing issues in recording death (listing numbers but not causes), the ignorance of local authorities on the causes of infant mortality, poor surveillance of the geographical spread of disease and disinterest in occupational health in the mills. The report decried the high deaths from meningitis, enteric fever and tuberculosis. It also accused the Corporation of promoting its own members to key public health roles instead of adequately qualified individuals (a thinly veiled reference to Henry Whitaker). The Commission agreed with the Citizens Health Committee that Belfast’s public health administration was ‘feeble’, ‘inefficient’ and ‘indifferent to their responsibilities’.[43]
In his aforementioned 1893 statement, Whitaker had blamed both the poor’s ignorance and the wealthy’s apathy for Belfast’s woeful health condition.[44] Undoubtedly, many working class families had a cavalier, perhaps fatalistic, approach to contagion. In 1899, measles killed 146 Belfast children but, knowing that measles rarely struck twice, parents allowed, even encouraged, infected children to mingle with others.[45] However, the positive examples set by other cities had proven the effectiveness of local government funding in stemming disease.[46] However, without an adequately funded public health infrastructure incorporating public education on the causes of infection, Belfast’s poor had few options other than continue struggling for survival in a pathogenic urban environment. While doing so, they watched the Corporation fund and erect Belfast’s most majestic civic buildings in the city centre including a new City Hall opened in 1906, just five months before spotted fever began to devastate the health of the city’s residents.
© The Author(s) 2021. Published by the Epidemic Belfast team on behalf of Ulster University. Any unauthorised broadcasting, public performance, copying or re-recording will
constitute an infringement of copyright.
[1] ‘Belfast Health Society’, Belfast Newsletter (5 January 1893).
[2] ‘The Health of Belfast’, Belfast Newsletter (1 March 1892).
[3] ‘The Health of Belfast’, Belfast Newsletter (2 October 1896).
[4] ‘Belfast Health Society’, Belfast Newsletter (23 February 1893).
[5] ‘The Sanitary State of Belfast’, British Medical Journal (3 October 1896), p. 953.
[6] ‘The Public Health of Belfast’, British Medical Journal ii (15 September 1906), pp. 648-9.
[7] ‘Sanitary Condition of Belfast’, Freeman’s Journal (3 October 1896).
[8] Stuart Irwin, ‘Managing a Mature Industrial City: Belfast Corporation, 1874-96. Unpublished PhD thesis. Queen’s University Belfast, 2019. To hear more about this research, watch this talk here: https://www.nidirect.gov.uk/articles/surviving-city-poverty-and-health-1888-1914.
[9] Anthony Wohl, Endangered Lives: Public Health in Victorian Britain (London: Methuen & Co., 1983), pp. 86-116.
[10] William Gray, ‘The Essentials of House Sanitation: How to Secure Them’, Reports and Proceedings of the Belfast Natural History and Philosophical Society for the Session 1891-92 (Belfast: Mayne and Boyd, 1893), pp. 111-32 on p. 114.
[11] ‘Belfast Health Commission. Report to the Local Government Board for Ireland’, House of Commons Papers, Reports of Commissioners, Cd.4128,vol. 31, 1908, p. 52.
[12] ‘Belfast Corporation – Outbreaks of Influenza’, House of Commons Debates, vol. 37 (6 July 1904).
[13] Graham Mooney, Intrusive Interventions: Public Health, Domestic Space and Infectious Disease Surveillance in England, 1840-1914 (Rochester, N.Y.: University of Rochester Press, 2015), p. 6.
[14] ‘Correspondence’, Belfast Newsletter (10 January 1893).
[15] ‘Editorial’, Belfast Newsletter (14 November 1898).
[16] Richard Clarke, The Royal Victoria Hospital Belfast: A History, 1797-1997 (Belfast: Blackstaff Press, 1997).
[17] ‘Belfast Corporation (Hospitals) Bill’, House of Commons Debates vol. 56 (26 April 1898).
[18] Jonathan Reinarz and Leonard Schwarz (eds), Medicine and the Workhouse (Rochester, N.Y.: University of Rochester Press, 2013).
[19] Select Committee on Belfast Corporation and Londonderry Improvement Bills. House of Commons Papers, 233, viii.283, 1896, p. 149.
[20] ‘Proposed Hospital for Infectious Diseases’, Belfast Newsletter (26 May 1891).
[21] ‘The Proposed Infectious Diseases Hospital: Local Government Board Inquiry’, Belfast Newsletter (20 July 1897).
[22] ‘The Proposed Belfast Infectious Hospital’, British Medical Journal ii(26 December 1896), pp. 1841-2.
[23] ‘The Infectious Diseases Hospital’, Belfast Newsletter (30 April 1900).
[24] ‘Correspondence’, Belfast Newsletter (17 April 1900).
[25] Greta Jones, Captain of all these Men of Death: The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (Amsterdam: Clio Medica, 2001), p. 104.
[26] ‘Correspondence’, Belfast Newsletter (17 April 1900).
[27] ‘Correspondence’, Belfast Newsletter (17 April 1900).
[28] ‘Belfast Health Commission. Report to the Local Government Board for Ireland’, House of Commons Papers, Reports of Commissioners, Cd.4128,vol. 31, 1908, p. 74.
[29] ‘Scarlet Fever Epidemic’, Weekly Irish Times (27 December 1913), p. 6.
[30] See also Janet R. Gilsdorf, Continual Raving: A History of Meningitis and the People who Conquered It (Oxford: Oxford University Press, 2020).
[31] ‘An Epidemic in New York’, The Times (4 April 1905).
[32] ‘Spotted Fever Death Roll’, Daily Mail (4 April 1907).
[33] William Osler, ‘Remarks on Cerebro-Spinal Fever in Camps and Barracks’, British Medical Journal, i:2822 (30 January 1915), pp. 189-90 on p. 189.
[34] Evening Echo (12 April 1907).
[35] ‘Spotted Fever: Tragically Sudden Death of Victims’, Daily Mail (13 April 1907).
[36] ‘Spotted Fever Tragedy’, Daily Mail (23 April 1907); Irish Independent (23 April 1907)..
[37] ‘The Slummer’s Revenge’, Daily Mirror (27 February 1907).
[38] H. Jaeger and L.L. Dock, ‘Cerebrospinal Meningitis’, American Journal of Nursing, 6:2 (November 1905), pp. 76-8.
[39] Carl Zimmer, A Planet of Viruses 3rd edn. (Chicago, IL: University of Chicago Press, 2021 [2011]), pp. 6-10.
[40] Irish Independent (5 February 1907).
[41] ‘Seventeen Deaths in Belfast’, Sunday Independent (3 February 1907).
[42] ‘School Attendance and Spotted Fever’, House of Commons Debates (20 June 1907).
[43] ‘Belfast Health Commission. Report to the Local Government Board for Ireland’, House of Commons Papers, Reports of Commissioners, Cd.4128,vol. 31, 1908, p. vi, 10, 19, 25, 32, 72, 73.
[44] ‘Belfast Health Society’, Belfast Newsletter (5 January 1893).
[45] ‘The Health of Belfast during 1899’, Belfast Newsletter (22 August 1900).
[46] Tom Crook, Governing Systems: Modernity and the Making of Public Health in England, 1830-1910 (Berkeley, C.A.: University of Berkeley Press, 2016).