Small-pox in Scotland and in Ireland
In their Final Report the Commissioners give us Tables of the death-rates from small-pox, measles, and scarlet-fever in Scotland and Ireland; and from these Tables I have constructed my [diagram (IV.)], combining the two latter diseases for simplicity, and including the period of compulsory vaccination and accurate registration in both countries.
The most interesting feature of this diagram is the striking difference in the death-rates of the two countries. Scotland, the richer, more populous, and more prosperous country having a much greater mortality, both from the two zymotics and from small-pox, than poor, famine-stricken, depopulated Ireland. The maximum death-rate by the two zymotics in Scotland is considerably more than double that in Ireland, and the minimum is larger in the same proportion. In small-pox the difference is also very large in the same direction, for although the death-rate during the great epidemic in 1872 was only one-fourth greater in Scotland, yet as the epidemic there lasted three years, the total death-rate for those years was nearly twice as great as for the same period in Ireland, which, however, had a small epidemic later on in 1878. Since 1883 small-pox has been almost absent from both countries, as from England; but taking the twenty years of repeated epidemics from 1864 to 1883, we find the average small-pox death-rate of Scotland to be about 139, and that of Ireland 85 per million, or considerably more than as three to two. But even Scotland had a much lower small-pox mortality than England, the proportions being as follows for the three years which included the epidemic of 1871-3:
- Ireland, 800 per million in the three years.
- Scotland, 1,450 per million in the three years.
- England, 2,000 per million in the three years.
Now the Royal Commissioners make no remark whatever on these very suggestive facts, and they have arranged the information in tables in such a way as to render it very difficult to discover them; and this is another proof of their incapacity to deal with statistical questions. They seem to be unable to look at small-pox from any other point of view than that of the vaccinationist, and thus miss the essential features of the evidence they have before them. Every statistician knows the enormous value of the representation of tabular statistics by means of diagrammatic curves. It is the only way by which in many cases the real teaching of statistics can be detected. An enormous number of such diagrams, more or less instructive and complete, were presented to them, and, at great cost, are printed in the Reports; but I cannot find that, in their Final Report, they have made any adequate use of them, or have once referred to them, and thus it is that they have overlooked so many of the most vital teachings of the huge mass of figures with which they had to deal.
It is one of the most certain of facts relating to sanitation that comparative density of population affects disease, and especially the zymotic diseases, more than any other factor that can be ascertained. It is mainly a case of purity of the air, and consequent purification of the blood; and when we consider that breathing is the most vital and most continuous of all organic functions, that we must and do breathe every moment of our lives, that the air we breathe is taken into the lungs, one of the largest and most delicate organs of the body, and that the air so taken in acts directly upon the blood, and thus affects the whole organism, we see at once how vitally important it is that the air around us should be as free as possible from contamination, either by the breathing of other people, or by injurious gases or particles from decomposing organic matter, or by the germs of disease. Hence it happens that under our present terribly imperfect social arrangements the death-rate (other things being equal) is a function of the population per square mile, or perhaps more accurately of the proportion of town to rural populations.
In the light of this consideration let us again compare these diagrams of Irish, Scottish, and English death-rates. In Ireland only 11 per cent. of the population live in the towns of 100,000 inhabitants and upwards. In Scotland 30 per cent., and in England and Wales 54 per cent.; and we find the mortality from zymotic diseases to be roughly proportional to these figures. We see here unmistakable cause and effect. Impure air, with all else that overcrowding implies on the one hand, higher death-rate on the other. This explains the constant difference between London and rural mortality, and it also explains what seems to have puzzled the Commissioners more than anything else—the intractability of some of the zymotics to ordinary sanitation, as in the case of measles especially, and in a less degree of whooping-cough—for in their case the continual growth of urban as opposed to rural populations has neutralised the effects of such improved conditions as we have been able to introduce.
But the most important fact for our present purpose is, that small-pox is subject to this law just as are the other zymotics, while it pays no attention whatever to vaccination. The statistician to the Registrar-General for Scotland gave evidence that ever since 1864 more than 96 per cent. of the children born have been vaccinated or had had previous small-pox, and he makes no suggestion of any deficiency that can be remedied. But in the case of Ireland the medical commissioner for the Local Government Board for Ireland, Dr. MacCabe, told the Commissioners that vaccination there was very imperfect, and that a large proportion of the population was “unprotected by vaccination,” this state of things being due to various causes, which he explained (2nd Rep., QQ. 3,059-3,075). But neither Dr. MacCabe nor the Commissioners notice the suggestive, and from their point of view alarming, fact that imperfectly vaccinated Ireland had had far less small-pox mortality than thoroughly well-vaccinated Scotland, enormously less than well-vaccinated England, and overwhelmingly less than equally well-vaccinated London. Ireland—Scotland—England—London—a graduated series in density of population, and in zymotic death-rate; the small-pox death-rate increasing in the same order and to an enormous extent, quite regardless of the fact that the last three have had practically complete vaccination during the whole period of the comparison; while Ireland alone, with the lowest small-pox death-rate by far, has, on official testimony, the least amount of vaccination. And yet the majority of the Commissioners still pin their faith on vaccination, and maintain that the cumulative force of the testimony in its favour is irresistible! And further, that “sanitary improvements” cannot be asserted to afford “an adequate explanation of the diminished mortality from small-pox.”
It will now be clear to my readers that these conclusions, set forth as the final outcome of their seven years’ labours, are the very reverse of the true ones, and that they have arrived at them by neglecting altogether to consider, in their mutual relations, “those great masses of national statistics” which alone can be depended on to point out true causes, but have limited themselves to such facts as the alleged mortalities of the vaccinated and the unvaccinated, changes of age-incidence, and other matters of detail, some of which are entirely vitiated by untrustworthy evidence while others require skilled statistical treatment to arrive at true results, a subject quite beyond the powers of untrained physicians and lawyers, however eminent in their own special departments.[9]