[From Causes of Consumption, 1899]
So far we have only dealt with those recognised causes of phthisis which we may consider to pertain to the external surroundings and life-conditions of the individual. We have failed, however, to find a sufficient cause or combination of causes to account for the extraordinary prevalence of the disease in the Isle of Man. On the contrary, we have found these conditions of such a nature as to convince us that they would naturally tend to produce a low phthisis rate.
It remains for us to study the constitutional idiosyncracies and characteristics of this people, and to consider whether the history of the race, and the social and domestic institutions affecting the individual, are in any way responsible for nurturing a special proclivity to consumption — a pro-phthisical constitution in fact. Should such a constitution be proved to exist it will be our duty to find out the various agencies that have been at work to produce it.
We have referred elsewhere, in a casual way, to the susceptibility of certain races to such diseases as syphilis, and the exanthems. It has been generally held that when a disease has been familiar to a race for a long time, the tendency is for the virulence and severity of that disease to abate, and moderate, to a great extent. Whether this abatement is due to an actual change in the type of the disease, such as might be produced by the mere act of passing through successive generations, or whether it is due to the slow process of immunization that the frequency of attack has brought about in the race itself, is a question with which we are not now concerned. As an example of this we may mention that syphilis is considered to be less serious in its effects than formerly; and it has even been noticed that the type of this disease, as found in old cities such as London, is distinctly milder than that met with in the provinces. Here the explanation is that either the type of London syphilis has changed and become milder through long residence in the city, or that the Londoner is becoming slowly immunized for the same reason. Since London syphilis proves quite as virulent as other types when transplanted in what one may be allowed to call "virgin soil," it seems very probable that the latter is the true explanation. On the other hand, when a disease is introduced to a people who have hitherto never suffered from it, even when it is of such a mild nature as measles usually is, it is likely to spread with wonderful rapidity, and to prove highly fatal.
It seems as though a certain pabulum is necessary to the existence of these diseases, and that it is found in greater abundance among a people that have not been ravaged by the particular disease, and in less quantity where attacks upon successive generations have more or less used it up The above remarks apply to diseases that are due to a specific micro-organism, and are of a highly contagious character, Though phthisis is due to a micro-organism, and although it is undoubtedly communicable, its pathology differs in a marked degree from such diseases as the exanthems. Moreover, although it has appeared among certain people in a more. or less sudden manner, and has spread with great rapidity after introduction, we can usually find some change in the mode of life and occupation of those people to account for the fact. On the ground of pathology and 'experience then, we must consider the case of phthisis as being altogether different to the diseases mentioned, and must also conclude that freedom heretofore from the disease does not 1n itself constitute an increased susceptibility. Furthermore we have no ground for supposing that this disease is of recent occurrence among the Manx.
A close study of the history and habits of this people will bring to light one fact very prominently; namely, that they are inbred to a very considerable extent. As has been pointed out before, the Manx of to-day are the outcome of the amalgamation of the original Celts with the conquering Norse. The Norse descents took place during the 10th, 11th, and half of the 12th centuries Since then, although various conquerors have subdued the Manx, they have had very little admixture of foreign blood. A patriotic and clannish spirit arose that resented the introduction of strangers, and so jealous did they become, that they went to the extent of enacting a law prohibiting ships' masters from landing foreigners on their shores under a heavy penalty. To all intents and purposes then we have a little nation some ten or fifteen thousand strong,1 living for 6oo years an isolated and detached existence. This in itself would not have been so bad, had there been a free and general mixing together amongst them. This was not the case however. The central mass of mountains formed a natural barrier between the north and south of the Island. Inter-communication could only be carried on along the narrow strips of lowland bordering the eastern and western coasts. But a greater barrier than the physical one existed in the natural aversion in which the northerner and southerner held each other. Although speaking the same language, and having the same religion, customs, and laws, they were descended from different races. Even to this day the types are distinct, the fairhaired, tall, Scandinavian, being represented by the northerner, while the more swarthy and thick set Celt has left his mark upon the southerner. From time to time fierce and bloody battles were waged between them, and enmity existed for centuries. The hand of time, however, has mitigated this bitter feeling, and it is only exhibited now in the form of a mild rivalry that crops up at such functions as Agricultural Shows, etc.
Midway between the two, situated on the east and west coasts respectively, are the village of Laxey and the ancient city at Peel. Laxey, undoubtedly, until recently, was in a particularly isolated condition The roads, both north to Ramsey, and south to Douglas, were simply rugged bridle-paths, winding along between the hills and the steep rock-bound shore, and continually crossing the narrow glens, through which ran the brawling mountain streams. It is only within the last half-dozen years that the old fashioned coach has given way to the electric tramway, which has brought Laxey into touch with the rest of the Island. Peel was not quite so isolated, for as it was the only port on the west, and being from time immemorial a place of residence for the Lords of Mann, it had dealings with both north and south.
We thus see that a small nation, isolated both by its own independence and by a stormy sea, becomes further broken up into four portions by its physical conformation and racial antipathies, namely :-that portion north of the mountains, that portion south of the mountains, and the small aggregation of farmers and fishermen that clustered round Peel and Laxey.
Douglas is of later date, and has, only of comparatively recent years, become the metropolis of Mona, and, consequently, it has drawn its inhabitants from all parts of the Island.
But a further sub-division still existed, for the people grouped themselves into the various parishes, and it was very rarely indeed that they migrated from one parish to another. Great resentment was felt against any man who married a wife from any but his own parish, and it was by no means uncommon for the couple to be pelted with sods and similar missiles. As an instance of this, I may mention that T_ K_ tells me that when courting his wife, who belonged to another parish, some 40 years ago, he only once visited her after dark, when he was so maltreated by the young men of her parish, that he never dare venture there afterwards, except by daylight. Also J_ G_, an old man now, solemnly avers, that when he brought home, to his native parish in the north, a wife from the south of the Island, a deliberate plot was laid to have him kidnapped and carried away by a passing vessel, a plot which happily failed. The natural result is that the inhabitants of such a parish as Bride, or of such a village as Cregneish, have been intermarried and inbred to such an extent, that one is not surprised to hear that they are all related.
When we come to study the surnames that are most frequently met with in the various parishes, we have very strong corroborative evidence of this consanguinity.
Let us take a list of the farmers of two parishes, one in the north and another in the south, say Bride and Rushen.
In order to represent more truly the state of things that obtained before the great changes of the last few years, we will go back to an old directory, dated 1863. Farmers in
Bruce, Robert, Ballacowle. Caine, William, Ballachrink. Caley, Philip, Kionlough. Christian, Charles, Ballafayle. Christian, Daniel. Christian, John, Ballacallow. Christian, Thomas, Thurot Cottage. Christian, William, Ballakey. Christian, William, Ballachree. Christian, William, Ballabeg. Christian, William C., Ballayonnage. Corkhill, John, Ballachree. Crowe, Evan, Ballamooar. Crowe, John, Ballakamain. Garrett, John, Ballachree. Garrett, John, Ballaghennie. Goldsmith, Thomas, Ballainin. Joughin Daniel, Ballaquirk. Joughin, Mark, Cronkbane. Joughin, William, Port Cranstal. Kaighen, Thomas, Ballagarret. Kelly, Charles, Ballakilmain. Kelly, Thomas, Skellag. Kewin, Charles, Ballakeish. Kewin, Thomas, Ballakilley. Kneale, James, Kimmeragh. Kneale, Thomas, Ballaganny. Lace, Thomas, Kerrowdhoo. Lace, Thomas, junn, Grenaby. Quarrie, Clark, Crosby. Quarrie, John, Ballavare. Quayle, Thomas, Kimmeragh. Radcliffe, Charles, Ballagarrett. Taggart, John, Ballalliergy. Taggart, William, Ballacowle. Teare, Daniel, Ballaskilly. Teare, -, Ballacondyer. Teare, William, Nassau. Teare, William, Ballacregga. Vondy, William, Ballacottier.
Bell, Thomas, Surby. Bell William, Ballafesson. Callister, William, The Howe. Carrin, Edward, The Sound. Clague, James, Rowena. Clague, Richard, Ling-yeig. Clague, Thomas, Rowena. Clucas, John, Ballakilley. Clucas, Thomas, Rowena. Cooil, John, Cronaback. Cornish, Henry, Ling-yeig. Corrin 'William, Ballaraee. Costain, John, Cronk-e-dooney. Costain, John, Cronkinooar. Crebbin, John, Ballacrink. Crebbin, John, Ballawood. Crebbin, Thomas, Fleshwick. Dawson, James, Scholaby. Gale, John, Strana Hall. Gawne, John, Little Rowena. Gawne, Thomas, Ballafesson. Gawne, Thomas, Calf of Man. Gawne, William, Glendowin. Griffin, John, Drogedfell. Griffin, Thomas, Ballahowe. Keig, John, Aristine. Kelly, Henry. Kennode, Henry, Croughlagh. Keruiode, Henry, Bradda W. Kernrode, John. Kinley, Edward, Ballakermode. Kinley, Thomas, Ling-yeig. Kincig, John, Ling-yeig. Kneen, Richard, Cross-a-Caley. Loway, Thomas, Ballarock. Maddrell, John, Ballalioo-den. Maddrell, William, Glen Chass. Moore, Thomas, Ballafesson. Moore, Thomas, Ballaglena. Moore, William, Fleshwick. Petrie, David, Ballacreggan. Preston, Richard, Ballachurry. Qualtrough, Richard, Surby E Qualtrough, William. Quayle, John, Port Erin. Radcliffe, James, Aristine. Sansbury, John, Surby. Taubman, Thomas, Cregneish. Taylor, John, Ballaqueeney. Taylor, John, Ling-yeig. Watterson, John, Bradda-mooar. Watterson, William, Corvalla. Watteison, William, Strand Hall,
On looking over this table we see that the names occurring in each parish are, with the three exceptions of Quayle, Radcliffe, and Kelly, entirely distinct. Even when we consider contiguous parishes, we see marked differences in the surnairnc lists, and each parish seems to have a few families that may be considered native to it ; as examples, we may mention the Kerruishes, of Maughold ; the Christians, of Bride ; the Corletts, Quayles, and Teares, of Ballaugh ; the Radcliffes, Sayles, and Teares, of Andreas ; the Wattersons, of Malew ; the Kinvigs and Cooils, of Arbory ; and the Kellys, of Laxey. These are just a few of the many cases that might be mentioned.
And when the small area and the small population of the parishes is considered, we find this point is very significant. Within an area of three or four square miles in the parish of Bride we get seven families of the name Christian 2 ; six of the name Joughin ; and eight of the name Kelly. There are only 63 families in the whole parish, and consequently these 21 families of the three names mentioned will naturally comprise one third of the total population, or some 213 individuals.
The Corletts, Quayles, and Teares, of Ballaugh, supply one-third of the population of that parish ; and the Kinvigs, Cubbons, Moores, Costains, and Cooils make up one-third of the population of Arbory. The same state of things will be found to exist in each parish. Many of the farmsteads have been in the hands of the families who now own them for 300 years and more according to the records, and how much longer still we have no means of knowing. The consequence is that these families undoubtedly married and intermarried with their immediate neighbours again and again. It is only when one has dwelt among this people that the extent of this inbreeding becomes apparent, and it is no exaggeration to say that three parts of the inhabitants are related to each other, and even where relationship is not acknowledged it is often found to exist unknown to the persons interested. I must here mention one little weakness in Manx character. -They are hospitable to a degree, and strictly honest, but, at the same time, they are exccedingly averse to parting with their money. This does not arise from avarice or penuriousness, but simply from a square-headed prudence and cautiousness. The land is freehold and in small holdings, and this is the chief wealth of the Manxman, Consequently, it often happens that, in order to keep the land in the family, consanguineous marriages are arranged by parents which are not always sanctioned by the natural affections of the young people.
To sum up, we may say that geographical position, physical conformation, racial antipathies, parish prejudices, and monetary considerations have all been at work for hundreds of years, and the result is, that a very high degree of consanguinity has been attained by the Manx people.
Is consanguinity a predisposing cause of phthisis? Most writers, while admitting it to be a cause, content themselves with a casual reference to it. For instance,
Dr. Ransome, whose excellent little treatise on the 'Causes of Phthisis ' has been referred to more than once in these pages, mentions consanguinity once only, and that is in the last chapter, where he says, " Darwin's researches on the danger of breeding in-and-in, and on the advantages of cross-fertilisation, together with the general experience of breeders of stock on the advantages of the selection of suitable and healthy strains, and the potent facts relating to the family inheritance of phthisis-all these have combined to make the heads of families cautious in sanctioning marriages with individuals suspected of having a tuberculous ancestry."
The majority do not mention it at all. There has long existed, however, a belief that consanguineous marriages are detrimental to the offspring.
Morgan 3 declares that exogamy was due to the observed evil effects of marriages of near kin, and also because it was known that intermixture of stocks increased both mental and physical vigour.
Sir John Lubbock 4 says that one of the causes was "the inferior energy of the children sprung from in-and-in marriages."
Sir H. Maine 5 agrees with Morgan on the ground that mixed marriages would give a better constitution.
Mr. Howitt 6 considers the Australian introduced the prohibition against the marriage of near kin to avoid observed evil effects.
Mr Fison, writing in the same book, cites a story from the Cooper's Creek Australians. "After the Creation," so runs the legend, "brothers, sisters, and others of the closest kin, intermarried promiscuously, until the evil effects of these alliances becoming manifest, a council of the chiefs was assembled to consider in what way they might be averted, the result of their deliberations being a petition to Muramura (the good spirit), in answer to which he ordered that the tribe should be divided into branches, and distinguished one from another by different names . . . . . the members of any such branch not to inter-marry, but with permission for one branch to mingle with another."
Certain Arab writers object to marriages other than with strangers, on the score that stronger children will be born when there is no relationship between the parents. Sir John Lubbock relates of the Kenaiyer that the custom of marrying out of the mothers' stock, having fallen into disuse, the old people assert that the mortality has consequently risen.
Much has been written to prove the ill-effects of inbreeding among stock, and authorities are pretty well agreed that enfeebled constitutions and consumption are common results. The chief diseases that we may expect to find resulting are those that are transmitted hereditarily. We can readily understand how this comes about, as hereditary influence is bound to be doubled when both father and mother transmit the failings of a common ancestor. But even when we have a perfectly healthy family history, we find consanguineous marriages are productive of various deformities and imperfections in the offspring. Dr. Mitchell 7 gives an instance of a village on the North-east of Scotland. The fishing population is estimated at 779, and contains 119 married couples, of which 11 couples are first cousins, and 16 are second cousins. Of the 27 marriages between near kin, 3 are barren, and from the remaining 24, 105 children were born or nearly 44 for every fruitful marriage and nearly 4 for all marriages between near kin, including barren ones. Of these 105 children, 38 are dead (of which 31 were in childhood) or 33·4 per cent.; 4 are deaf mutes, or nearly 6 per cent.; 4 are imbecile and 4 more slightly silly; one is paralytic, or 1·5 per cent.; and 11 or a little over 16·4 per cent. are scrofulous and puny. The children of those who are first cousins are described as "all of them neither strong in mind nor in body."
Sir Thomas Watson says of the Faroë Islands that phthisis is very rare, but mental derangement is common, as many as one per cent. being thus afflicted. Here we get a great deal of inbreeding.
The "Pall Mall Gazette," August 5th, 1872, in a biography of the late Mr Augustus Smith, for a long time owner of the Scilly Islands, says that he removed some of the inhabitants of the outlying islets to better neighbourhoods. On some of these the scanty resident householders - never forming connections out of their own island - had, it is said, degenerated into a condition approaching that of imbecility. The upper classes of the Azore Islanders, owing to the general desire to hoard wealth, are in the habit of inter-marrying very closely among themselves, so that marriages even in the third degree are very frequent. They are very ignorant, and are contented with their ignorance ; the strain of Moorish blood in their veins tinges their habits and customs, and they are mean and parsimonious in their way of life. The Hon. F. Monson, in the Consular Reports, 1871, No. 4, finds an unnatural frequency of idiocy and enfeebled constitution among them which he considers a consequence of their consanguineous marriages.
The diseases and defects referred to by these various observers, it will be noticed, are such as are usually held to be transmitted by heredity
Huth 8 himself, who to a certain extent is an apologist for the marriage of near kin, and who, after quoting some of the above extracts, inserts other cases of consanguineous marriages that give negative results, in conclusion says :-"And, however doubtful the above evidence may leave us, whether in-and-in breeding generally leads to good or to bad results, there can be no rational doubt after studying the effects of crosses, that in-and-in breeding cannot create disease, but at most is able to intensify an hereditary taint."
Now we do not for a moment entertain the idea that in-and-in breeding creates consumption, but we do maintain that any hereditary taint of consumption is bound to be intensified wherever consanguinity exists.
We have clearly asserted already that although consumption as a disease is rarely if ever transmitted from parent to child, the predisposition and the specially suitable con stitution decidedly are transmitted, and our argument is that it is this hereditary transmis sion of the pro-plrthisical constitution, intensified by the centuries of in-and-in breeding, that is the cause parexcellence of the excessive frequency of the disease in the Isle of Man. I find that this opinion is generally accepted among the more thoughtful laity, and although this in itself is not sufficient to warrant us in accepting it as a fact, it undoubt edly has weight in backing up the concensus of medical opinion ; and I have found that, without exception, those medical men I have questioned on this point-and I have questioned many-are agreed that consanguinity is the great cause of phthisis here.
Dr. Haviland, in the lecture already referred to, says :-
The social causes are divisible into two classes, one of which can only be removed by instilling into the people of all classes (remember I say all classes, without distinction between the rich and the poor) sound knowledge of the causes of the disease, and sound principles to guide them in doing their utmost to avoid perpetuating the one grand cause of the prevalence of consumption in this and other similarly circumstanced conununities-consanguineous intermarriages.
Dr. Miller, of Laxey, thus writes the :-
Then, and for many years previously, the people of Laxey and surrounding district intermarried in a most promiscuous fashion, with the result that they became nearly all more or less related to one another. From what I can gather, consumption was then most prevalent. I know many of the older people have lost several of their children (in some cases as many as 8 or 10) from this disease, and my predecessor, Dr. Friend, who was Medical Officer to the Mines for over ten years, informed me that in his time seven out of every ten deaths here were due to tuberculous disease. There is nothing like that proportion now, and every year the number of cases is diminishing. I attribute this marked improvement to the fact that there is now, and there has been for some years, much greater intercommunication between the people of this district and the outside world, and, consequently, intermarriage between persons of the same blood has become a rarity.
With regard to the geographical distribution of phthisis in the Isle of Man, we consider it of comparatively little importance. The whole population, from Point of Ayre to Calf of Man, live under circumstances, as regards climate, soil, and occupation, so similar in character, and the whole area of the Island is so small, that the slight variations in the amount of consumption in the parishes from time to time are by no means of a significant character, and are due undoubtedly to a great extent to chance. There is, however, one fact that stands out clearly, and that is, that there is a notorious amount of consumption in Lonan, and an equally remarkable freedom from it, comparatively speaking, on the western side of the Island. This seems to suggest a distributive cause, and we believe this cause to be consanguinity.
As we pointed out in an earlier chapter, Lonan has been exceptionally isolated, owing to its geographical position. This fact has been responsible for a very great amount of in-breeding, as Dr. Miller points out in his letter to me quoted above. We may safely say that Lonan is more consanguineous than any other parish in the Island, and hence the heavy death-roll from consumption of 41·17 per 10,000 persons living.
We also pointed out that Peel and the western parishes, lying midway between north and south, and being easy of access from both, and also from the fact of the political importance of Peel, and its being the chief outlet and inlet for the Island for many centuries, naturally had more opportunities of introducing fresh blood, and, consequently, would suffer less from in-breeding than the other towns and parishes. We, therefore, get a low phthisis rate for the whole western division, namely: 21·94; as against 24·19, 28·15, and 24·53, for the northern, eastern, and southern divisions respectively; and we also get the lowest parish phthisis rate, namely: Michael with 15.19.
During my researches I have come across several family histories that illustrate, in a very marked way, the tendency of heredity and consanguinity, when coincident, to cause terrible havoc among the offspring. The family I select, in order to conceal identity, we will call Orry. This family have been landowners in the parish they now dwell in since their ancestor, the famous King Orry, landed on our shores. They are a tall handsome family, and have produced some of the strongest men in the Island. The family is split up into some dozen or so branches, but since they still cluster together in the same neighbourhood, no doubt they are more or less in-bred. I will distinguish the different branches by mentioning the farms on which they live. Under each person who has died of consumption I place the letters ph.
CONSUMPTION IN THE ORRY FAMILY. Wm. Orry, Ballalough. John Orry, Ballachrink. Thomas Orry, Ballamoor. | | | --------+------+ +-------------+-------------+ +-------++-----------------------------+ | | | | | | | | | | | | | | Helen Samuel Charles married Sarah. Annie. Effie. Ernest. John married Alice. Florrie. Edmund. Richmond. Maud. Mona, ph. ph. killed. ph. ph. living. ph. living. ph. ph. ph. ph. ph. ph. | | | | | | | +-------+-------+ | +--------+-----+ Tom | John | ph. +-------+-------+ ph. +--------+-------------------------------------------+ | | | | | | | | | | Jane Thomas James. Gertrude. Lucy. Nora. Susan. George. Herbert. Bertha. ph. living. ph. ph. ph. ph. ph. ph living. living. James Orry, Ballawhy. Henry Orry, Ballahow. Thomas Orry, Ballawhane. | | | | +-------+----+ +--+ | | | | Thomas married Jane. Philip married Mona. ph. ph. | | | | | +------+------+ +--------------+ | | Susan +-------++------------------------------------+ living. | | | | | | | | Esther. Martha. Ruth. Helen. Bessy. William. Alfred. +-------+------+ ph. ph. ph. ph. ph. ph. ph. | | | Ennest. Mary. Alice. ph. ph. ph. (abroad.) Walter Murtoch, Ballarue. Cæsar Orry, Ballabane. Larry Qualtagh, Balleigh. | | | | +-----+------+ +------+------+ | | | | | | John married Sarah. Evan. Cæsar married Mona. Edgar. | ph | | ph. +-------+------+------+ Henry +----------+----------------------------------------+ | | | | | | | | | | | | | | | +---------+ | | | | | | | | Evan. Alice. Emily. | | Stephen. Clement. Cæsar. Larry. Thomas. Eva. May. Eliza. ph. ph. ph. Charles. Herbert ph. ph. ph. ph. pli. ph. ph. living. | ph. living +-------+------+-----+ | | | | Hugh. Polly. Evan. Joseph. ph. ph. ph. ph.
We do not believe that heredity and consanguinity, no matter to what extent they may co-operate, could ever create a single case of phthisis, but we are certainly of opinion that they can create a condition of body and tissue that will render the offspring pre eminently susceptible to infection, whenever brought into the immediate vicinity of an existing case of phthisis. The tubercle bacillus alone can cause phthisis, and the tubercle bacillus must originate from a previous case of tuberculosis. The opportunities for infection by this bacillus are innumerable. We are daily and hourly exposed to it ; but fortunately, the particular state of body that is necessary for the reception and lodgement of this powerful agent is comparatively rare.
When, however, we get whole families, that, by injudicious intermarrying, have attained this particular state of body, we can easily understand that a single case of phthisis brought into their midst will be a serious menace to all its members. A knowledge of the nature of the disease, and of its particular mode of dissemination by means of the sputum, would, no doubt, enable many to escape its ravages, but amongst the Manx there is an absolute disregard of the most rudimentary laws of isolation and personal hygiene. I know of cases where six, seven, and even eight persons have died of phthisis in the same room, and on the same bed; where familiarity has bred such contempt of this disease, that the surviving brothers and sisters have actually had to wear the clothing of the latest victim-and that, without the slightest attempt at cleansing the same-they, in turn, falling victims within a year or so. In some of the secases, half-a dozen children have habitually slept in one small stuffy bedroom, the doomed victim sleeping in their midst. I have rarely seen any attempt to either destroy or disinfect the sputum, the patient, as a rule, expectorating promiscuously.
Some couple of years ago I was called to a family some few miles out of Ramsey. The eldest daughter, aged 16, was dying of phthisis, the second daughter I found to have unmistakable signs of the same disease, a third daughter was beginning to cough and to lose flesh, while the boy was to all appearance well, though evidently not of a strong constitution. All four, along with the father and mother, slept in a small bedroom. I at once advised the father to send the two younger children, who were as yet free from consumption, away from home. This was done, and a course of tonics caused the threatening symptoms in the girl to disappear. The two elder daughters died within a month or two of my first seeing them. I instructed that the house was to be thoroughly disinfected and cleaned, and the bedroom whitewashed, before the two surviving children were brought home again. These two children are strong and healthy and have had no threatening symptoms since. There is no doubt but that in this case the healthy children were becoming infected through being brought into such intimate contact with the diseased ones, especially under such unwholesome conditions as the small bedroom imposed upon them.
Carelessness no doubt is to some extent responsible for this state of things, but ignorance is chiefly to blame, for it must be remembered that there is such an amount of fatalism inbred in this people with regard to consumption, that the medical man who might give practical advice as to isolation and disinfection and the proper care of such cases, and timely warning as to the dire results to the other inmates that may be expected to follow if such advice be neglected,-after the first definite pronouncement that consumption has set in, is seldom seen at the bedside until the closing scene, and not always then. It is a foregone conclusion with them that the doctor can do no good, that the disease is fatal in fact ; and it is by no means uncommon for the practitioner to be called upon to fill up the death certificate for a patient whom he last saw some months before.
After a careful study of the whole question of consumption in the Isle of Man, let us briefly review the various points that have come to light.
In the first place, we find an excessive amount of the disease, which we may estimate roughly at twice that which obtains in England and Wales. There must be a cause for this excess. We have failed to find a sufficient cause either in climate, soil, mal-nutrition, occupation, or impure air. We have proved that the Manx by the inbreeding of centuries have been reduced to a high degree of consanguinity. And, lastly, we have expressed it as our conviction that this high degree of consanguinity is responsible for producing the pronounced proclivity to consumption that exists here, and that this pro phthisical constitution, plus the many opportunities for contagion that a profound ignorance of the nature of the disease brings about, causes the high phthisis mortality which is the bane of the ancient and historic Manx people.
In conclusion, we may be permitted to add a few words with regard to the best means to be adopted in order to rid the Isle of Man from consumption, for we believe this can be accomplished. To put the matter concisely, we would say three things are to be done, viz.:-Legislate, educate, isolate.
Concerning LEGISLATION, we would recommend that phthisis be added to the list of notifiable diseases. If this were done, the Parish and Town Commissioners could enforce the carrying out of such precautions as would tend to minimise the chances of the disease spreading by infection. Such precaution would naturally include the proper disinfection and destruction of the sputum, and of such articles of clothing, &c., as might be con taminated ; the isolation, as far as practicable, of patients in their own homes from the other inmates ; and the thorough cleansing and disinfecting of the rooms in which phthisical patients have died. Similarly, tuberculosis in cattle should be scheduled in the Contagious Diseases (Animals) Act ; facilities should be afforded the farmers for applying the tuberculin test ; public slaughter-houses only should be used, where all inspector, appointed for the purpose, would be able to examine the meat intended for human consumption. With regard to the compensation of butchers for the loss sustained through the seizure of tuberculous carcases, the recent Royal Commission on Tuberculosis reported against it, and suggested a system of insurance.
Under the second head we would say that legislation will be of but slight avail if the people are not EDUCATED in hygiene and sanitary principles. Phthisis is a disease that is very insidious in its onset, and often of a more or less chronic character when developed, two facts which make it very difficult for sanitary authorities to deal with. On the other hand. the infective organisms are limited so strictly to the sputum, that thorough disinfection is a very simple matter. We thus see that where legislation fails, education may step in and enable the victim, with very little inconvenience, to prevent those with whom he associates from becoming contaminated. It is high time the laws of health were taught in every elementary school in the land. Such instruction would be equally useful from a purely educational standpoint as, say geography, or history, and would prove of infinitely more service in promoting the health and happiness of future generations.
With regard to the third head, we would point out the good that may be done by ISOLATION of the tainted in suitable sanatoria. On the one hand, this removal of the phthisical from the general community, frees the public from a very real source of danger ; and, on the other, it very materially increases the patients' chances of improvement and ultimate recovery. The number of recoveries that take place in these sanatoria is surprising, and one of them, situated in the Black Forest, claims that, in the first stage, 27·8 per cent. are absolutely cured, and 31 per cent. are nearly cured; in the second stage, 6·83 per cent. are cured, and 14·6 per cent. are nearly cured.
The treatment consists principally in insisting upon the patients spending most of their time in the fresh air. For this purpose sites are selected at a considerable elevation above sea-level. In the central highlands of the Isle of Man, with their bracing, ozone laden breezes from the sea, absolutely free from the impurities of town life, we have situations eminently suitable for sanatoria ; situations easy of access by means of the excellent mountain road and the electric tramway which runs to the summit of Snaefell, Some; 2,000 feet above sea-level. With the judicious planting of trees of the pine variety, which thrive well in our climate, we would have a sanatorium second to none in the kingdom, where we could not only treat our insular cases, but which would year by year attract greater numbers of sufferers from the mainland.
With regard to CONSANGUINITY little need be said, as the spread of education, the broadening of peoples' views, the breaking down of parish prejudices, and the greater facilities for the introduction of fresh blood which fast steamers to and from the surrounding countries, and the spread of railways and tramways on the Island now afford all these things are tending to cause this evil to disappear from our midst. We are starting late in the race, heavily handicapped by an exceedingly high phthisis mortality, still I believe that, with all the advantages that Nature showers upon us in this little ocean gem-advantages arising from climate, soil, sea, and mountain-and aided by the excellent physique and constitution of the natives, the Little Manx Nation may yet be the first to proclaim that it will no longer sacrifice its sons and daughters to this dread disease-CONSUMPTION
1 I find in an old history of the Isle of Man, probably the first published, the following:-" Mr Curwen says, that at the commencement of the last century, the number of inhabitants on the Island was under ten thousand. In 1755, he computes them at fifteen thousanb. In 1777, only twelve years after the revestment, the numbers had increased to twenty thousand. They are now estimated thirty- five thousand." John Feltbarn, who published 'A Tour through the Island of Mann, 1797 and 1798, says that Lieut-Governor Shaw computed the population to he 30,000 to 33,000 in 1797. The above Mr Curwen was M.P. for Cumberland; and also a member of the House of Keys.-C.A.D.
2 Directory for 1894.
3 Ancient Society-pp. 69, 74, 424, 409.
4 Origin of Civilization-p. 130.
5 Early Law- pp. 227-228.
6 Fison and Howitt : " Kamilaroi "-PP. 4, 5.
7 Memoir read before the Anthropological Society of London, 1866.
8 " Marriage of Near Kin," p. 293.
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