There is a history of over 200 years of public health service in Ireland, and by the early nineteenth century county infirmaries, fever hospitals and public dispensaries had become the most important providers of health services. As can be imagined, the public health service, then as now, was highly political. The dispensaries in particular, and their organisation, provided an arena in which venality and heroism were regular combatants, setting sordid scheming against a varied, disparate and doughty medical profession. The dispensary at Tallaght was typical, and on this local stage all the characters of a national preoccupation played out the politics of funding such a service and availing of it at this local level.
R. P. Burkitt was the dispensary doctor in the 1830s dealing with Tallaght, Ornagh (now known as Orlagh) and Saggart, an area with a population of 6,337. Dr Burkitt had to visit and treat the sick poor in their homes and attended one dispensary every day. He attended all cases personally where medical or surgical aid was required, and he reported to the Poor Inquiry in 1834 that his annual ‘case load’ varied from 1,000 to 1,200 cases per year from 1831 to 1833. The dispensary was supported by voluntary subscriptions of a minimum of one guinea (£1-1s) raised locally, and the county grand jury could provide matching funding. The service was to be available free of charge only to the very poorest in the area, and under the rules on no account were services to be provided free to those who subscribed. Dr Burkett’s salary was 100 guineas (£105) per annum, and dispensary accounting worked on the basis that if he allowed his expenses, including cost of medicines and rent, to become excessive he suffered a reduction in his annual salary sufficient to balance the books. He provided dispensary accounts for the three years 1831 to 1833, and in this period he received his full salary only in 1833. For this amount and an additional £22 worth of medicine, the dispensary service provided relief to about one in six people of the local population annually. Among the medical problems mentioned were industrial accidents, cholera in 1832 and influenza in 1834.
‘Food of a coarse sort, sometimes deficient in quantity’
Dr Burkitt also discussed the nature and causes of diseases, and he considered want of proper food to be a major one. He described people as ‘generally badly clad and eating food of a coarse sort, sometimes deficient in quantity, and not suited to whatever diseases the people suffer from’. Their bedding was described as consisting of a blanket and bad quilt and a coat or cloak thrown on straw, often upon the ground. He also described badly furnished and ventilated cabins, ‘which are deficient of the necessary comforts’. His reference to the doors and chimney being the only source of ventilation indicated that many of the cabins of the poor were without windows. Since the doctor made a point of describing it as one of his duties to attend at the homes of his patients when required and to be in daily attendance at the dispensary, he was in a position to know the daily lives of the poorest in the parish in a way that other commentators could not.
No detailed information was gathered by the Poor Inquiry concerning the dispensary at Tallaght other than the questionnaire completed by Dr Burkitt. The inquiry did, however, conduct public examinations at dispensaries in adjoining counties, from which we can extrapolate the issues with which Dr Burkitt and his various subscribers were concerned.
Many of the dispensary reports in the Dublin area mentioned vaccination against smallpox. This was still relatively new, having been developed by Dr Jenner in 1796. At Baldoyle there had been frequent cases of the disease, and it was reported that the medical officer thought that the confidence of the public was a little shaken. At Clane and Donadea the opposite was reported. Here vaccination was performed every day when applied for, and smallpox was not recently common in the area. ‘The confidence of the public in the efficacy of the vaccination appears from the numbers that are vaccinated to be increasing.’ At Celbridge the medical officer reported that ‘he considers vaccination to be decidedly preventive of smallpox, which has very seldom appeared in the district of late years. The confidence of the public is gradually increasing in its efficacy.’
Access and funding
The subscribers of a minimum of one guinea each elected a governing committee of not less than five people, and the county, through the grand jury, was authorised to match the annual subscription. Concern was expressed in some of the reports that the dispensary committee could arrange subscriptions so as to persuade the county to pay a higher amount. This seems to imply that some of the ‘subscriptions’ were made in return for some consideration. The accounts for the dispensary at Tallaght illustrate the balance of power in this matter (above right).
Access to dispensary services was a difficult issue, as was funding them. At Baldoyle the medical officer reported that nobody was ever refused advice or medicine but that to have a recommendation from a subscriber was the regular course for accessing the services. ‘Many of the farmers and some others who subscribed required that they themselves, their families and all living on their farms should be attended gratis.’ This seems to echo the answer of Dr Burkitt to the Poor Inquiry, when he wrote of the holders of small portions of land who were recommended by subscribers as proper objects. At Clane the report stated that a recommendation from a governor entitled a person to relief. ‘The servants of subscribers are attended.’ Here also it was reported that ‘neither is attendance given gratuitously to any of the poorest subscribers’. This contrasted with the position reported in Baldoyle. The Celbridge report sets out the rule in that area:
‘Those who have obtained the recommendation of a subscriber are alone entitled to relief. Each subscriber is, however, permitted to issue an unlimited number of orders, so that no person can, under ordinary circumstances, be excluded from the benefits of the institution, which there is no reason to believe are extended to any others than those whose circumstances place them really in need of gratuitous assistance. The lower servants of subscribers are considered to come within the latter description, but neither advice nor medicine is ever given to a subscriber as such.’
The dispensaries appear to have had a pharmacy in which were stored quinine and morphia, among other drugs. Clane, Donadea and Celbridge reported that leeches were available when symptoms rendered them expedient. We can safely assume that at Tallaght Dr Burkitt kept a supply of quinine and morphia among his medicines and that he also used leeches to bleed patients when considered efficacious. He would also have been expected to vaccinate against smallpox, but public acceptance of vaccination and public confidence in its effectiveness varied depending on local experience and perception. There would have been midwives in the locality but the doctor may have become involved in difficult cases. The dispensaries investigated did not have any great supply of surgical instruments, and at Celbridge these were confined to those used in the extraction of teeth. Apart from these, the medical officer was obliged to have recourse to his own stock of instruments. At Clane the dispensary reported that they possessed splinters, bandages etc. to render assistance in case of fractures or other injuries. No extra payment was made to the medical officer for the use of his horse, which he had to supply from the salary provided. HI
Seán Bagnall is an accountant and lawyer.
Further reading:
R. D. Cassell, Medical charities, medical politics—the Irish dispensary system and the Poor Law, 1836–1872 (Suffolk, 1997).
L. M. Geary, Medicine and charities in Ireland, 1718–1851 (Dublin, 2004). Poor Inquiry, Ireland. First report from her Majesty’s Commissioners for inquiring into the condition of the poorer classes in Ireland, HC 1835 (369) XXXII, appendix B.