[From Causes of Consumption, 1899]

CHAPTER VI.

CAUSES OF CONSUMPTION IN THE ISLE OF MAN.

In discussing the causes that tend to produce an exceptional prevalence of any given disease in a particular locality, we do not expect so much to find any new factors, but rather to find a single factor that acts in an excessive degree, or a combination of several factors that bring about the same result. At the same time, though we do not discover any new cause, we may possibly give a new importance to a cause that has previously been considered of minor influence. And so in considering the subject of Insular con sumption, we shall find that a cause has been at work that hitherto has not received that attention it deserves. Perhaps this may be accounted for by the fact that it is only when we study the disease in an insulated and small community like the Manx, that this particular cause assumes any great importance.

It is a well-known fact that causes that produce a fatal malady in one individual may leave another who has been equally exposed to their operations, unharmed. This invulnerability is due to what, for want of a better name, is called resistance. This resistance though generally accompanied by a vigorous and healthy constitution is not so accompanied invariably. The converse is equally true that susceptibility, or want of resistance, does not necessarily imply a weakly and enfeebled constitution. The con ditions that bring about a greater or less degree of resistance in the few, may operate on the many ; and so we may get communities, nations, and even races that are specially prone to, or free from certain diseases, as witness the easy prey the South Sea Islander falls to such diseases as syphilis and the exanthems genërally on the one hand, and the immunity enjoyed by the negro from malaria on the other.

We thus see that in approaching this question, the various causes fall naturally into two broad divisions, namely, those that affect the surroundings of the individual such as climate, soil, occupation, etc., and those that affect his personal p-)wers of resisting disease, such as the influence of race and family, and the various vicissitudes and changes that go to make up the history of his people.

We propose to discuss the subject somewhat in the order observed in the first part of this thesis, and we shall try and give to each cause its relative importance and true 'Ialue in producing an excessive amount of phthisis in the Isle of Man.

CLTMATE.

We have described in some detail the climatic conditions under which the Manx live, and it remains only to read these details in the light of Chapter I. to come to a definite conclusion as to whether our climate does, or does not, tend to accentuate the phthisis death-rate. Though most will refuse to admit that climate may actually cause phthisis, it would be folly to assert that it has no influence on the disease when existant. The climatic treatment of consumption grows in favour daily, and we do not exaggerate when we say that thousands of lives are prolonged and made happy, and many even permanently cured, each year by this means.

The intimate association of the organs affected-the lungs-with the external air, and the delicate medium through which that association is kept up-the lining membrane make it very apparent that climate must affect the disease in one way or other. It will be easily seen, therefore, that an unfavourable climate, though not actually a cause, may so aggravate the disease when started as to very materially affect the death roll, and have a, by no means, small influence in bringing about an unusually high phthisis rate, for it must be borne in mind that whatever causes an exaccerbation of the disease, increases the power of dissemination by contagion.

To summarize the facts arrived at already, we may say that the temperature of the Isle of Man is more equable than that of any other part of the British Isles, being some what higher in autumn and winter, similar in spring, and lower in summer.

There is comparatively little frost and snow, and absolutely no fog. Its sunshine is much greater than in any surrounding district, and stands third on the list of the British Isles. The winds seem to be somewhat similar in velocity to those on the mainland, though, owing to our being freely exposed on all sides, we no doubt feel them more. The rainfall is a rather complex subject, as we have some very wet portions and some exceptionally dry, while the majority of the Manx people enjoy the happy medium. The combination of mountain and sea air seems to be conducive to an excess of health-giving ozone, and certainly has a most invigorating and bracing effect on the system. Mountain and sea air are notoriously much freer from organisms than the air of plains, and Dr Henry Bennett ascribes the beneficial influence of the climate of Mentone to the fact that the air breathed by the inhabitants must come either off the sea, or else over a range of mountains 4,000 feet in height.

After a careful study of the whole subject one is forced to the conclusion that the climate is in no way to blame for the excessive amount of phthisis that obtains in the Isle of Man. We must rather say that phthisis is prevalent here in spite of the climate. Dr. A. Haviland, in urging the Manx people to rid themselves of this disease, says " For Nature is in your favour, and your climate will render your efforts even more successful than those of your English neighbours," and, again, . . . "were a con tingent of 2,000 incipient consumptive cases sent over from England I should know where to place them to their advantage, provided house room were supplied. Within this parish, or in the adjoining Baldwins, are to be found sites for consumption hospitals and sanatoriums, although I would not confine myself to those localities, for there are many other spots in this Island that would fulfil all that could be required of them in this respect. In fact there is not a parish even where the highest mortality from this disease obtains, but what can boast of some spot where the true climate of the Island can be enjoyed."

Sir James Young Simpson, Bart., who was well-known in this Island owing to his frequent vacation rambles among our heather-clad hills and fertile dales in pursuit of his favourite study of archaeology, both in his public lectures and in private practice, recom mended the Island to his patients and his friends as being especially suitable for invalids.

Dr. Thomas Wise, who spent 15 years in practice here, and who was held in very high repute as an able doctor, thus writes : " In my practice I came to the conclusion that if a phthisical patient were protected from the strong winds which prevail there, the Isle of Man would be a per%ct sanatorium for such a case. No doubt different individuals require different climatic treatment, as they do dietic or medicinal remedies ; yet the Isle of Man, with the condition I have named as to the shelter from strong winds, is, in my opinion and experience, an excellent resort for those suffering from chest disease."

With regard to the influence of strong wind on the disease. we may be excused for enlarging, as it has been held by so great an authority as Dr. Haviland, that wind, and wind alone, is the cause of the peculiar geographical distribution of phthisis in the Isle of Man. He asserts that wherever you get a high phthisis rate, you will find that that district is in a peculiar manner exposed to the full force of the wind, either a bleak plateau or plain, or a funnel-shaped valley. He takes each parish separately, and adapts his theory to the figures obtained. Unfortunately, his figures were based on a three years' calculation, and these figures by no means represent the true distribution of the disease, for when a longer period of 15 years is utilised, we find that in many cases, though the amount and force of the wind have not varied, the phthisis mortality for the various parishes has very materially altered: In referring to the exceedingly high death rate from phthisis in the parish of Bride, which amounted to 6583 per 10,000 living, Dr. Haviland explained that it was due to its open and exposed position, with a low coast line that offered no resistance to the wind. At the southern extremity of,the parish run the Bride Hills in an east-to-west direction, and he contended that the parishes to the south of these hills would naturally have a less mortality than Bride, which they certainly had on the three years' calculation, On the 15 years' basis, however, we find an entire reversal, as Bride is slightly below the Insular average, and with the exception of Maughold, has a lower phthisis rate than any other northern parish, while the parishes to the south of the Bride Hills, which have whatever shelter these hills may afford, have a phthisis rate considerably higher than the Insular average.

Since the prevailing winds in the Isle of Man blow from a westerly quarter, and since the western coast line does not in any way break the force of the wind before it sweeps the adjoining parishes, we might naturally expect the western division to give us the highest phthisis rate. Instead of this, however, it gives us the lowest, and the parish of Michael, probably the most windswept in the Island, has actually the lowest phthisis rate, namely r5-ig. The parish of Lezayre, which is almost an inland parish, and includes the sheltered valleys of Sulby and Glen Auldyn, ought to be fairly free from phthisis, but we find its rate to be 29·04. Lonan, containing the Laxey Glen, is certainly a funnel-shaped valley, and its phthisis rate is the highest in the Island. Its exposure, however, is to the East, from which quarter we get comparatively little wind, and we shall point out later that other causes may be responsible for the terrible phthisis rate of 41·17 per 10,000.

In studying the distribution of consumption among a small nation and over a small area of land, we do not feel justified in formulating general principles nor in refuting the same, especially when put forward by so great an authority as the gentleman quoted above, nevertheless, we feel bound to say that, after careful investigations covering a period of fifteen years, we find that the results obtained, can in no way be considered to support the theory that strong winds are accountable for the peculiar distribution of the disease in the Isle of Man, whatever may be the case elsewhere.

With regard to the rainfall of the Island, we are convinced that it does not in any way contribute to the consumption rate, for we find that the worst parish, from a phthisical point of view, which is Lonan, has a rainfall considerably less than the parishes of Marown and Maughold, which are considerably below the average in the matter of consumption. And again, the parish of Rushen, with the high rate of 29·76, has a very low rainfall indeed.

From a lifelong experience of the Manx people, the last five years of which has been spent as a general practitioner among them, I have come to the conclusion that we have a climate eminently suitable for the treatment of lung diseases. The mild and balmy air seems to allay all pulmonary irritability, and consequently the harsh day cough of phthisis and the difficult breathing of asthma generally disappear after a short residence on our shores.

The removal of patients from climatic conditions often depressant, with raw damp weather and frequent fogs, and the toil, din, and smoke of large cities, to an island whose unrivalled natural beauties are combined with a pure crisp oxygen-laden air, redolent of gorse, heather, and the glorious sea, acts like a charm and improvement sets in at once.

The mildness of our winters is not sufficiently well-known to our neighbours, or we should have greater numbers of invalids wintering here. As it is the number is con tinually increasing, and many to my knowledge come over quite regularly when the cold weather sets in. I have again and again seen the harsh cough, anorexia, and hæmoptysis of phthisis disappear after a short residence here in the winter time, and for several years in succession, a lady patient of mine of some 50 years of age, whose lungs were pronounced tubercular by both Dr. Dreschfeld and Dr. Ll. Roberts as well as by her family doctor, was driven over here on the first approach of winter, where she not only lost her distressing symptoms, but actually gained weight and vigour, and was comparatively free from illness until the ensuing winter forced her to seek refuge once more in our midst. This lady died recently in Grays, Essex, of phthisis. One might give a long list of such cases, but this example, which is typical of the rest, will suffice to show that, whatever may be the cause or causes of our local phthisis, climate has no part whatever in its production, but rather that its healthful character prevents our phthisis roll being heavier than it is.

SOIL.

The soil of the Island is fairly dry and well-drained, with the exception of the boggy portion of the parishes of Ballaugh and Lezayre, known as the Curraghs. and this neighbourhood is so very sparsely populated that any ill effects that might arise from the damp soil are limited. Moreover our experience is that there is very little consumption on the Curraghs, but a fair amount of rheumatism.

MAL-NUTRITION.

The Manx people are thrifty and industrious, and although few may be called wealthy, there are fewer still in absolute want. Their habits are so simple, their wants so few, and the necessaries of life so very cheap, that hunger and cold are seldom felt. A generous spirit of charity is found among all classes, and the poor and the old are so well looked after that mendicancy is almost unknown. Potatoes, bacon, salt-fish, and wheaten bread are the staple food for the poor, and these can be had at exceedingly low prices. I have never yet come across a case of mal-nutrition due to poverty in town or country, and, as a rule, the natives are well-nourished in body and happy and contented in mind.

OCCUPATION.

There are two chief occupations which the bulk of the people follow, namely, agriculture and fishing. The soil is fairly good, and, in parts, actually rich, and the climate and verdure make it eminently suitable for stock-rearing. The land is not in the hands of large landlords, but is owned by the peasantry in crofts varying from 20 acres to 200 acres in extent.

The fishermen are most numerous in the towns, but numbers are recruited from the country districts annually for the manning of the Peel fleet, which engages in the fishing both of the West of Ireland and the North of Scotland. These men are not only remarkable for the intrepidity and skill with which they follow their hazardous calling, but are, as a rule, fine specimens of manhood-big, burly, brown-haired fellows, worthy sons of their Viking forefathers. The boats are well-manned and sea-worthy.

A very large number also follow the sea as mariners ; in fact, with the exception of Newfoundland, no nation furnishes so big a proportion of sailors out of its population as the Isle of Man.

Farmers, fishermen, and sailors, form the bulk of the male population, and we know that these men, with their free active life in the fresh air, ought to be particularly healthy and robust ; and this we find to be the case. Certainly we cannot look upon their callings as being in any way of a nature to predispose to phthisis.

In former times the lead mines of Laxey and Foxdale were among the most successful in the United Kingdom, and a goodly number of men were employed in their. Now, however, only some 200 are employed at Laxey, and about 450 at Foxdale. They are a healthy class of men, and are not particularly liable to lung troubles. Dr. A. Miller, of Laxey, who is Surgeon to the Mines, has furnished me with the following particulars concerning them :-" Taken as a whole the miners are a wiry and healthy race, and I think their general health will compare favourably with the rest of the population ; but the miners as a class have much deteriorated here of late years, as the best men have left this place for Africa, and other great mining countries."

At the first glance, one might be inclined to connect the high phthisis rate in Lonan, with the presence of the Laxey Lead Mines. A few moments consideration of the facts, however, will dispel this erroneous idea. If mining were the cause of a high phthisis mortality in Lonan, we might fairly expect the male population to suffer to a much greater extent than the female. The total number of deaths from phthisis in Lonan during fifteen years was 193, Of these, 93 were males and 100 were females. The mean male population was 1,598, while the mean female population was 1,526. We thus see that although the females in the whole Island preponderate over the males by some 3,000, yet in Lonan we get some 70 less females than males. The annual average of deaths from phthisis among males in Lonan was 6·20, for females 6·66, and when worked out proportionately we find that for every 10,000 males living we get 38·79 dying of consumption, while from a like number of females we get 43·64 sharing a similar fate. The ratio for the whole Island as is seen in Table XII. is 25·34 males to 26·04 females per 10,000 of each sex respectively. We thus perceive that although both sexes participate in producing this terrible death-rate of 41·17 per10,000, the females are responsible for a very considerable number over and above their due proportion as calculated according to the figures for the whole Island.

It is very evident, therefore, that the occupation of the inhabitants of Lonan in no way accounts for their consumption.

With regard to Foxdale, it is sufficient to state that the phthisis rate for the parish of Patrick, in which the mines are situated, is so low as 22·78, although here, as at Lonan, the males are in a majority. We may, then, conclude that mining is in no way a cause for the consumption in the Isle of Man.

The rest of the population are engaged in the various callings necessitated by a vast tourist traffic during the summer months, and also the usual trades and occupations incident to town life generally. To sure up, we may say that the chief occupations are both healthy in themselves, and carried out under conditions that preclude the possibility of their being in any way a cause, either actual or predisposing, of consumption.

IMPURE AIR.

In no part of the Island are men or women herded together in any numbers, either for industrial or any other purposes. The country cottages are, however, in inany cases, any thing but sanitary or well ventilated. Many of them are small double-roomed "tholthans," with thatched roof, a clay or mud floor, an open hearthstone for burning peat, and a wide chimney, through which the smoke may or may not find its way. The windows are small and not made to open and shut. In these hovels one finds a family of anything up to a dozen, living and sleeping as best they can Some are dirty, many are clean, none are ventilated, and most are damp. The very wretchedness of these cabins, however, often prevents their being stuffy, and the " boisterous Manx winds," the old writers were so fond of blaming as being a fruitful cause of consumption, generally find some hole or cranny in the ill-constructed walls or roof, through which they may carry on a little ventilation in spite of the inhabitants. This class of dwelling is now rapidly disappearing, and, as they become uninhabitable through sheer age and senile decay, more commodious and healthful cottages are erected in their place.

*The farm houses and better-class workmen's dwellings are very fair, and, as a rule, sanitary and dry.

The establishment of Parish Commissioners, and a strict code of sanitary regulations and by-laws, is producing a very beneficial result already, .ind when once the natural conservatism of a secluded and insular people is overcome, we shall no doubt have little cause for complaint, for once they are convinced that the the new order of things is better than the old, the thing is as good as accomplished. It is the convincing that is the difficulty.

In the older portions of the towns the streets are narrow and the houses small. There are no portions of the smaller towns, however, but are freely swept by the pure air from either country or sea, and the phthisis rate consequently compares very favourably with the country districts, namely :-Ramsey, 21·41 ; Peel, 24·66 ; and Castletown, 21·40. Douglas being a larger town, and the poorer districts consequently being shut in, has suffered to the extent of 27·19. Dr. Haviland, in 1883, said of it

" I lately have inquired into the sanitary conditions of some of your worst streets, and, for the purpose of comparison, I selected seven of the most populous streets in the old part of Douglas-in the " black spot area," in fact-and compared the mortality from consumption in those streets with what took place in all other parts of the town. The result was as follows : .In the seven overcrowded and filthy streets of the "black spot" order, the deaths from consumption were at the rate of 72 to every 10,000 living, thus exceeding the death-rate at Kirk Bride by 6·17. In the remaining streets in Douglas the death-rate amounted to 29·00 to every 10,000, or a difference between two parts of the town of 43 in 10,000 of the inhabitants-a contrast which few suspect, although it exists in their midst."

Since that time Douglas has been transformed to a very great extent-old portions pulled down, and streets widened. The phthisis rate has also come down from. 29·46 to 27·19, although the town has considerably increased in size, and is consequently more "built in." Still the same black spot areas are to be found, and the same congested portions, with their narrow streets and blind alleys, help to swell the number of victims each year. We believe that these conditions are, to a great degree, responsible for there being from 3 to 6 per 10,000 more deaths in Douglas than in the other towns. Rebreathed and impure air, is, therefore, a cause in the Isle of Man as elsewhere, though perhaps not to the same extent as in our great manufacturing centres.

DISEASED FOOD.

We have no reason to suppose that tuberculosis in cattle is more prevalent here than in England. Certainly the Manx, as a nation, are by no means great flesh eaters, the largest amount being eaten in the towns, which compare favourably with the country districts as regards phthisis mortality. Moreover, we are convinced that the tubercular diseases of childhood, which may be reasonably considered to originate from the milk of tuberculose cows, are by no means as common here as in England. We may, therefore, conclude that the cases of phthisis which may be traced to the consumption of diseased food are exceedingly rare in the Isle of Man.

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