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Selected research areas and preliminary conclusions

Selected research areas and preliminary conclusions

Analysis from this research project is in the process of being written up, and the following presents a few indications of the directions of research. More details and papers will be posted in due course.

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Far fewer deaths on the island of Skye were medically certified than in the town of Kilmarnock, a difference that was particularly large for infants.

Socio-economic and demographic profiling of doctors and patients

Aims

The first strand of this project seeks to identify, for each doctor registering deaths in the four communities, their age when they made the diagnosis, the institution at which they were medically educated, the date of their qualification, whether they were a physician, a surgeon or a general practitioner; their employment history and their sources of finance while in their current position. For example Dr. Rankin in Kilmarnock is noted in the Medical Directory as being both a ‘colliery surgeon’ and an ‘assurance company medical referee’, and Dr. Frew was a ‘medical referee’ under the ‘Workman’s Compensation Act (London and Provincial Medical Directory). In addition individual and collective socio-economic profiles of the patients for whom each doctor certified the cause of death have been created from the information gathered from the linked civil registers and censuses created in the course of the Demography of Victorian Scotland project. Maps have been created allowing both the extent of a doctor’s practice, and the nature of the area he served, to be gauged. These also give an indication of the different distances which had to be covered in urban and rural areas in order to seek medical help. Where individual doctors are considered, research is concentrated on those who certified at least 100 deaths in the study areas, 24 doctors in Kilmarnock and 14 on Skye.

Preliminary results

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The expanding town of Kilmarnock had more resident doctors than the Isle of Skye: overall there were under half as many doctors on Skye at any one time as in Kilmarnock, but a smaller and declining population on the island means that although at the beginning of the period there were only about 3 doctors per 10,000 people, by the end there were, as in Kilmarnock, around 6. The horizontal lines in the above figures show the duration of individual doctors in Kilmarnock and Skye respectively. While there were some doctors who stayed a long time in each place, there were also a great many who spent only a few years in Kilmarnock or Skye. Analysis of dates of qualification and places of birth suggests that those who stay only a short time tended to be at the beginning of their careers, and usually certified few deaths, suggesting they were gaining experience as an assistant to a more experienced doctor. Those with family links to a place were more likely to settle there. Skye appears to have a smaller proportion of long-staying doctors, which may be due to the poverty of the population, and the additional time and expense involved in traveling long distances, rendering it more difficult to make a decent living.

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For example, Dr James Brown of Uig, North Snizort, on Skye, practicing between 1873 and 1998, with the duties of public vaccinator and parochial medical officer for the parishes of Kilmuir and North Snizort on the Trotternish peninsula, did not travel more than about ten miles as the crow flies to certify deaths. However the map of the communities in which he certified deaths shows the settlement pattern around the coast and hints at the mountain range occupying the interior of the peninsula. A round trip to his more distant patients could therefore have been up to forty miles.

Distances in Kilmarnock were much smaller, but doctors still appear to have had spatially differentiated certification practices:

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The number of deaths certified per year in each enumeration district varied by doctor even in Kilmarnock, although most of the doctors lived in the centre of the town.

Work is ongoing.

Exploration into causes of death

Aims

The second strand tabulates which doctors certified deaths as being from particular causes, thus enabling us to ascertain the extent to which diagnoses of cause of death varied over time due to a different mix of medical personnel, to a changing clientele, to progress in medical knowledge, and to changes in the incidence or lethality of certain diseases. A range of statistical techniques, including multivariate and multilevel modelling, will be employed in order to unravel the complex inter-relationships at work.

Preliminary results

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The majority of deaths on Skye were not certified by a doctor, and the range of causes proffered by medical men was very different to those suggested by the informant of the death. This figure shows causes of neonatal death (deaths in the first month), indicating that ‘pleurisy’ was a common suggestion by informants, but was not a cause offered by doctors. Lay people were also much more likely to confess ignorance of the cause, particularly if no doctor had seen the infant. The age pattern of causes of death on Skye, however, with a larger than expected number of deaths 5-8 days after birth, suggests that neonatal tetanus might have been present on the island, although doctors did not mention it as a cause.

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In contrast, virtually all deaths in Kilmarnock were certified by a doctor. This figure also shows neonatal deaths, with percentages assigned to different causes by individual doctors, who are arranged from left to right by date of qualification. The popularity of atrophy and debility as a cause shows remarkable variation by individual doctor, which does not appear to be entirely explained by cohort. Some doctors (particularly, but not exclusively, father and son, Donald and William Macleod) were much more keen on prematurity than on atrophy and debility. Although there is no indication in the age structure of tetanus being a particular problem in Kilmarnock, the few tetanus deaths there were, were concentrated, again, among the two Macleod doctors, as well as James Rankin, and it is notable that Donald Macleod published a paper in the Glasgow Medical Journal in 1859 on idiopathic tetanus.

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Individual doctors varied in their ascription of causes among deaths to older infants too. Kilmarnock doctors are again arranged in a left to right order of increasing qualification date. In general, enteritis was a more popular cause among doctors in later cohorts, and teething was restricted to a handful of doctors, two of which (James and Guthrie Rankin) who may have been father and son. Despite the larger percentages ascribed to teething by Macfarlane and the younger Rankin, variation in the numbers of infant deaths certified means that it was others qualifying in the 1850s who clocked up the largest numbers of teething deaths after James Rankin. One might expect the acquisition of further knowledge to affect practices, but there is no evidence of individuals losing their affinity to teething as a valid cause of death. James Rankin was presumably exposed to new ideas though his membership of the BMA and presidency of the Ayrshire Medical and Social Club, but his teething deaths were spread fairly evenly over his 33 years of practice in Kilmarnock, suggesting that some doctors remain wedded to old, often obsolete ideas.

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It is likely, however, that new ideas regarding ‘convulsions’ as a cause of death managed to filter through to individuals. The previous figure shows that convulsions was more popular among earlier cohorts (see figure above). Furthermore, the current figure shows, for long-serving doctors, the percentage of infant deaths ascribed convulsions in different decades, and suggests that convulsions lost popularity among the majority after the 1860s, reflecting a move away from recording of symptoms to an assignation of disease.

Respiratory diseases show similar patterns of an increase in the popularity of pneumonia and influenza as causes of death among individual doctors, at the expense of bronchitis certifications. Work is ongoing.

Urban-rural differences

Aims

Third, it is intended that a greater understanding will be obtained of the contrasts in the availability of medical services to people living in rural areas compared to urban areas in late nineteenth century Scotland, and how this may have had an impact on the diseases reported to the Registrar. Data from Skye, Torthorwald and Rothiemay will be used to investigate differences between rural areas to assess the challenges posed by ‘remoteness’ as opposed to ‘rural living’.