Pulmonary consumption; its prevention & cure, established on new views of the pathology of the disease

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

COLLECTION OF

Preface

Some apology is requisite for publishing another book on the subject of pulmonary consumption, so many works, and several of them possessing sterling merit, having already appeared before the public. When, however, the rapid advances of pathological science, and the continual improvements daily making in its several departments, are taken into account, it will not at all appear extraordinary that a new work should come out on the very important and engrossing subject of pulmonary phthisis — a malady which interests so large a proportion of the inhabitants of these countries, that any advance made in the knowledge of its pathology, and consequently of its treatment, cannot fail to excuse, and even justify, the confidence of an author in thus venturing on an arena already occupied by so many and

11 PREFACE.

such distinguished pathologists. The new views in the pathology of phthisis now for the first time presented to public notice in this essay, have been the resultof close and unremitting attention to thedisease for some years, partly in this country, and for some time in Paris, in the clinical wards of the celebrated Louis. One thing must at all events be conceded, namely, that if my views possess no other recommendation, they possess at least that of novelty and originality ; at the same time that the method of preventing the disease, as well as of treating it, when established, deducible from my notions of its pathology, cannot but tend to promote the health of the patient, and to retard the progress of this distressing and hitherto irresistible malady, even though these views may not as yet be stamped with the approving seal of my professional brethren. By some it will doubtless be deemed extraordinary, nad perhaps redolent of something very like transcendental vitalism, thus to invest, as I have done, with all the attributes of personality, and almost of perceptivity, those hitherto slighted beings, whose existence has been too long deemed rather metaphysical than real, — I mean, the lacteal vessels

PREFACE. Ill

those active agents of nutrition, and supporters of the body corporal. True it is, that I lay it down as the grand and prominent feature of my pathology of phthisis, that it consists primarily in a want of discriminating power in the mouths of these vessels, whereby they are so far changed from their natural state, as to admit those inorganizable parts, the residue of the materials of nutrition, which in their normal and healthy state they instinctively rejected. In thus endeavouring to trace the origin of this disease, too often considered local, I am borne out by many bright examples in the profession. The mischief of confining our views of phthisis to the mere cavity of the chest, and of looking no farther, appears of late years to be recognised by those who have written on this disease. These gentlemen have insisted on the importance of attending to the function of digestion in the treatment of this disease ; a point of paramount importance, it must be admitted, but not more so in phthisis than in many other serious diseases ; they have, however, as it were with one accord, stopped short of what I conceive to be the true origin of the disease ; they have "•one only as far as the deterioration of the function

IV PREFACE.

of digestion j I have gone farther, to the function of nutrition ; a view of the subject which, though perhaps hypothetical, is much better supported by facts, as also by the results of treatment, than any of those which have preceded it. There is one point in the pathology of phthisis which still requires clearing up : it is, whether the process of ulceration is absolutely necessary for the dislodgment of tubercles from the lungs. The solution of this problem is beset with many and serious difficulties ; the chief difficulty being referable to the consideration as to whether tubercular deposits are so far removed beyond the precincts of vitality as to be exempted from the influence of the agents of absorption. The solution of this important question would contribute much to modify and improve our present views regarding the treatment of this disease. In thus presenting these my views of the pathology and treatment of phthisis, I trust that my desire to contribute my mite to the alleviation of human suffering will plead my apology with my professional brethren.

London, June, 1842.

Chapter I. Statistical Observations On Consumption

Hokate.

The very general want of information, on the part of the public, with respect to the vast and awful mortality annually resulting from pulmonary consumption, renders it necessary to enter somewhat at length into its statistical history, before we consider either its pathology or treatment. By tracing out the fatality consequent on this disease, in some of our large cities, and in counties remote from each other, we shall be better able to form an opinion as to the influence which locality and its concomitant circumstances may possess over it. Considerable interest must also attach to the inquiry as to how far the production and extension of this disease may be influenced by variety of climate.

B

This last subject will be rendered very clear by considering respectively the influence of sudden transitions of temperature, as well as the effects of cold, heat, humidity, and dryness, on this disease. To these might be added many other advantages likely to accrue from statistical inquiries, such, for example, as the influence of certain occupations, of sex, and of age.

I cannot help noticing the vast importance of the present subject to insurance societies. They who speculate on human life ought certainly to be familiar with the circumstances which tend to shorten it ; and a statistical history of consumption must therefore claim a leading place among the data on which they form their calculations.

I have often been astonished when I contrasted the terror struck into mankind by the occasional appearance of some devastating epidemic, more especially when it ran its course in a short period, with the apparent apathy and cold indifference with which they look on at the frightful and equally certain, though slower havoc, daily committed by this insidious scourge. Were cholera or fever to break out in this metropolis to-morrow, every family, possessing the means, would precipitately abandon the town, and while securing themselves from the inroads of danger, and even when in some safe retreat, would not fail to lament the fate of those left behind. Here the fear of contagion very naturally creates alarm for their own safety, but still the praiseworthy and humane feeling of pity for those necessarily exposed to its influence, does not cease when they themselves are remote from danger. Might we not naturally expect that a similar spirit of commiseration would display itself, in behalf of the thousands that are annually falling victims to that never-ceasing, and hitherto most mortal, of all maladies — pulmonary consumption? Were cholera to manifest itself, public measures would be instantly adopted to protect life ; but consumption is permitted to ravage our cities, and carry off whole families, without resistance or apparent regret. With the exception of two small and poorly-supported Infirmaries, in London, whose means of relief are totally disproportioned to the counteraction of the ravages of this dire malady, there exists not in Great Britain a single institution exclusively devoted to its treatment, whether preventive or curative. The only charitable mode of accounting for such

b 2 extraordinary apathy on the part of the public is, by admitting the almost universal dearth of information which exists with respect to the awful devastation committed by this disease. I shall, therefore, endeavour to give further publicity to the mortality resulting from consumption, by circulating more widely some facts which, from their nature and undoubted authenticity, will, I sincerely trust, induce those who are blessed with the means, to assist their less affluent countrymen, in escaping from the most disastrous of all the maladies to which flesh is heir.

Part I. Mortality From Consumption

There is no disease so universal, and none so mortal, as consumption of the lungs. According to the best data, it has been calculated, by medical men, that it causes one-fourth part of all the deaths occurring from disease in Great Britain and Ireland. Among the many who bear testimony to this startling fact, I might name Dr. Young and Dr. Woolcombe. Dr. Abercrombie, of Edinburgh, whose observations are generally very correct, says: "Deaths from consumption, in the British

ON CONSUMPTION.

islands, have been calculated, on the most moderate computation, at one-fifth of the whole mortality, and there is much reason to fear that the evil is increasing."* Here the calculation is in regard to the whole mortality, and were it in relation to the deaths from disease only, one-fourth part might be assumed as the proportion, as calculated by Dr. Young and Dr. Woolcombe. The testimony of medical evidence is therefore very unanimous ; but even if we discard the opinion of the profession, and take official reports as a guide, we shall still find the preceding statement confirmed. The Annual Reports of the Registrar-General of Births, Deaths, and Marriages, drawn up in compliance with the Registration Act, furnish us with the most accurate statements of the causes of death, throughout England and Wales, that have hitherto been collected. I shall therefore avail myself of the First Annual Report, as presented to both houses of Parliament in 1839, by command of her Majesty.

The total number of deaths registered in England and Wales, from July 1st to December 31st,

* Edinburgh Medical and Surgical Journal, vol. xvii. 1821.

O STATISTICAL OBSERVATIONS

1837, both inclusive, amounted to 148,701. Of this number, 27,754 were the result of consumption of the lungs, of whom 12,968 were males, and 14,786 were females. We therefore find that, according to this authentic report, consumption caused twenty per cent, of the total number of deaths, thus confirming Dr. Abercrombie's opinion, that one-fifth part of all deaths are the consequence of this fearful malady. But if we take away 12,691 deaths from old age, and 4845, which were violent, in all 17,536, we shall then find that consumption produced upwards of a fifth part of all those which resulted from disease, thus bearing out the opinion of Dr. Young and Dr. Woolcombe, that one-fourth part of the deaths occurring from disease is the result of phthisis. The whole evidence is therefore singularly unanimous.

According to the Report of the Registrar-General, pulmonary consumption destroyed more human lives during the six months referred to, than did cholera, influenza, small-pox, measles, ague, typhus-fever, hydrophobia, apoplexy, hernia, colic, diseases of the liver, stone, rheumatism, ulcers, fistula, and mortification !

For the satisfaction of the inquisitive reader, I shall give the mortality resulting from each of these diseases, during the six months already referred to, and, when I have placed them in juxtaposition, shew the difference between the number of their victims and those of phthisis.

Extract from Table A, contrasting the Rate of Mortality from Consumption with that from Sixteen other Diseases : —

DISEASE.

MALES.

FEMALES.

TOTAL.

Cholera - -

Influenza

Small-pox - - -

3,050

2,761

5,811

Measles - -

2,340

2,392

4,732

Ague

Typhus Fever -

4,439

4,608

9,047

Hydrophobia - -

Apoplexy - -

1,447

1,264

2,711

Hernia - - -

Colic - - - -

Diseases of Liver -

1,018

1,909

Stone - - -

Rheumatism - -

Ulcers - - - ■

Fistula - - - -

Mortification

26,881

12,968

14,786

27,754

By the above table it is shewn, that from July 1st to December 3 1st, 1837, pulmonary consumption destroyed eight hundred and seventy-three more lives than did all the other diseases in this list combined. Such a fact needs no comment ; for it at once points out as strongly, as it does clearly, to those who feel an interest in the protection of human life against what malady their efforts ought to be most particularly directed. There surely can be no more satisfactory evidence required in proof of the mortality, whether absolute or relative, occasioned by consumption.

We cannot flatter ourselves into apathy by denying the authenticity of the Registrar-General's Report, as from the care which each individual local Registrar is compelled to use in registering a death, we may infer that we are now furnished with information as near the truth as it is possible to arrive. This vast mortality from phthisis may appear surprising to those who have not hitherto attended to the causes of death ; still the above facts cannot be controverted. It may startle the consumptive invalid, nevertheless the truth will hold good.

But additional interest and much useful information may result from inquiring into the influence of certain localities, in diminishing or increasing the mortality from this disease, and in so doing, let us commence with the metropolis.

The total number of deaths that occurred in this vast city, from July 1st to December 31st, 1837, both inclusive, was 24,959, being nearly at the rate of one every ten minutes. Of this number 3877 were the consequence of consumption, namely 1947 males, and 1930 females, so that London loses about one soul every hour throughout the whole year by this malady. One circumstance must, however, be observed : we have already seen that phthisis produces twenty per cent, of the total number of deaths occurring in England and "Wales, or in other words, that every fifth death, from whatever cause, is the result of this malady. But from the statement relative to London individually, we perceive that here scarcely every sixth death is produced by consumption. Although large cities are proverbially unhealthy, and pulmonary affections generally considered to prove very fatal in such localities, nevertheless, there are few towns or rural districts so free from phthisis, in proportion to their population, as

London. I am also perfectly satisfied that phthisis takes longer time to run through its stages, in the metropolis, than in many of the most healthy rural districts, and there can be nothing more unwise than for those who are unhappily afflicted with this malady, to leave town for country air. If they can afford, in the commencement of the disease, to go abroad, and remain in some clime where the temperature is moderate, but, above all, regular, with an atmosphere impregnated with moisture, then the change may prove useful, but to repair to the country districts of England is decidedly unwise. Devonshire is often selected as a retreat for the consumptive invalid, but we shall best arrive at the true value to be placed on such a fashionable resort, by comparing the number of consumptive deaths occurring there with the whole, so as to obtain their relative proportions, and then contrasting them with those of London.

From July 1st to December 31st, 1837, both inclusive, there were 4801 deaths in Devonshire. Out of this number 835 were the consequence of phthisis; namely, 389 males and 446 females. Thus we find, that of the deaths occurring in this favourite retreat for the consumptive invalid, one-fifth were the result of consumption, whereas in the smoky metropolis there were not quite one-sixth. It has been argued by those whose attention I have directed to this subject, that from the salubrity of the climate of Devonshire, invalids repair thither in the last stage of consumption, and falling victims to the malady, consequently cause this great mortality. But, on the other hand, it must be allowed, and I can affirm it, from personal observation, that for one patient who goes to Devonshire for the sake of climate, one hundred come to and remain in London for professional advice ; and from their protracted application for relief, often sink under their affliction, and swell the metropolitan bills of mortality in a much greater ratio than can possibly be the case with those of Devonshire, from the comparatively few phthisical patients who repair thither.

In order that we may contrast the proportional number of deaths, occurring from consumption in London, with those in some other large towns, we shall select as examples Birmingham and Leeds.

From July 1st to December 31st, 1837, both inclusive, the total number of deaths that occurred in Birmingham was 1459, of which 354 were the result of phthisis, namely, 190 males and 164 females. The number of consumptive deaths in Birmingham, as compared with those in London, appears not a little surprising. In the metropolis less than one- sixth of the aggregate mortality is referable to this malady, whereas in Birmingham every fourth death is attributable to its ravages.

During the period above cited, namely, from July 1st to December 31st, 1837, both inclusive, the total number of deaths which took place in Leeds amounted to 1582, out of which 335 were the result of phthisis, namely, 161 males and 174 females. We, therefore, here find the mortality from consumption comparatively great, upwards of a fourth part of the whole deaths resulting from it.

It may not be devoid of interest to contrast some other rural district with Devonshire. For this purpose we shall select Norfolk and Suffolk conjointly. The total number of deaths occurring in, these two counties, from July 1st to December 31st, 1837, both inclusive, amounted to 6017. Of these 1306 were the consequence of consumption, namely, 582 males and 724 females. A fourth part of the population would therefore appear ultimately to fall the victims of this malady in this district ; so that pulmonary phthisis may be fairly considered more prevalent in Norfolk and Suffolk than in Devonshire or London.

These illustrations might be extended, so as to embrace almost every district in England and Wales ; but on comparing the other counties and towns, I find the results so devoid of any peculiar interest as to render further comment useless.

It may be observed that the absolute mortality from phthisis, in reference to the population, is, according to the Registrar- General's Report, " nearly four annually out of one thousand living."

It is matter of regret, that in Scotland and Ireland there is no annual return made of the number and causes of deaths. We cannot therefore avail ourselves of any authentic document, with the view of ascertaining the relative mortality from consumption in these countries ; but, from hospital and dispensary reports, we may infer, that they are not more exempt than England from the visitations of this scourge.

I cannot let pass this opportunity of expressing my grateful acknowledgments to my highly-talented friend, W. Farr, Esq., for the valuable assistance I have derived from his elaborate statistical researches, from which, not only the medical profession, but the public generally, cannot fail to obtain much curious and useful information.

The inference to be drawn from the preceding statistical observations on the mortality from consumption is, that every fifth death occurring in Great Britain and Ireland is the consequence of this disease ; and if we exclude deaths from old age and unnatural causes, every fourth death is the result of this malady. We also see, that although one-fifth part of the total mortality is attributable to this disease, nevertheless that some districts are not so subject to it as others — a circumstance which may be ascribed alike to climate, the habits, occupations, and modes of life of the inhabitants.

If these facts relative to the vast destruction of human life, consequent on phthisis, are not sufficient to arouse public attention to adopt measures for the protection of life from this scourge of humanity, nothing will ever do so. Comment must consequently be useless, if these glaring facts fail in eliciting compassion ; I therefore leave the subject.

Part II. Increase Or Decrease Of Consumption ?

It may very naturally be asked, whether or not the mortality from phthisis is on the increase or decrease. In order to answer this question with any degree of accuracy, we should not only require to be furnished with correct bills of mortality for such a number of years as we include in our calculations, but, in addition to these, we ought to have a return of the population for each year during that period. As we are not in possession of documents on which reliance can be placed, this question must remain unsettled, further than the vague and wide calculations we may deduce from former reports.

It has been argued, that the method of calculating the relative mortality, as compared with that from all diseases, is wrong, and that we ought to take the absolute mortality in reference to the population. This is, no doubt, strictly correct; for some seasons when phthisis has been unusually fatal, the proportion of deaths from this cause, when compared with the total number, has appeared small. An epidemic, such as cholera, may swell the bills of mortality so much, as to render the proportion of deaths from phthisis comparatively small, although, in fact, the absolute number of such deaths may have been in reality unusually great. Nevertheless, by extending our observations over a number of years, we shall arrive very near the truth, even by discarding the population, for we all ultimately fall the victims of disease, if we except the few instances of unnatural deaths ; for even where a demise is ascribed to old age, nevertheless some organic or functional disease is the direct cause. And fatal epidemics are so rare, and generally so confined to districts, as scarcely to influence the accuracy of our calculations made by taking the relative mortality from consumption, as compared with that from all other causes. As all mankind must ultimately be swept from this terrestrial scene by the stream of mortality, the proportional share which phthisis has hitherto taken, and still takes in this office, must, if carefully attended to, bring us very near the truth, in solving the problem under consideration.

It must be obvious that the personal experience of any medical man can throw no light on the subject, beyond the variations occurring in his own field of practice during the few years of his professional life. If, therefore, we wish to compare the gradual variations in mortality from phthisis as they occurred during past ages, we must necessarily depend on former reports, while to arrive at a knowledge of the relative mortality between these periods and the present time, we can only contrast our recent reports with those which our predecessors have left.

We are furnished with a most valuable work on Statistics by J. Marshall, Esq.,* which, in addition to much other truly important information, shews the annual mortality in the metropolis during a period of two hundred and four years, namely, from 1629 to 1831, both inclusive. Tn his tables he has also specified the causes of death ; consequently there is, perhaps, no more valuable guide than this, on which we can rely for the information now sought. Availing ourselves of this work, we shall go back to the year 1629, and calculate the proportional share of deaths

* Mortality, &c, of the Metropolis, by J. Marshall, Esq , London, 1832.

C produced by consumption, from that period, during intervals averaging ten years, up to 1830:

YEAR.

TOTAL NUMBER

DEATHS FROM

PROPORTION FROM

OF DEATHS.

CONSUMPTION.

CONSUMPTION.

10,554

1,827

One-fifth.

14,059

2,423

One-fourth.

15,046

2,757

One-fifth.

15,842

3,087

One-fifth.

19,067

3,272

One-fifth.

21,460

3,473

One-sixth.

20,471

2,678

One-seventh.

24,620

2,706

One-ninth.

25,454

3,054

One-eighth.

26,761

3,728

One-seventh.

30,811

4,919

One-sixth.

23,727

4,543

One-fifth.

19,830

3,776

One-fifth.

22,434

4,594

One-fourth.

20,517

4,889

One-fourth.

18,038

4,852

One-third.

23,068

5,721

One-fourth.

19,893

5,427

One-third.

19,348

3,959

One-fourth.

21,645

4,704

One-fourth.

From the above table we may infer, that pulmonary consumption has of late years decreased in the metropolis ; for, from the year 1770 up to 1830, it averaged one-fourth, and sometimes as high as one-third of the whole mortality, whereas now and for some years back, it has not exceeded one-sixth. The variations occurring during the period embraced -in the table are, however, very considerable, and shew that in 1701, 1710, 1720, and 1730, the deaths from phthisis were proportionally fewer than they even are now. Sir James Clark, in his Treatise on Consumption, gives a table, constructed from data contained in Mr. Marshall's work on the Mortality of the Metropolis, and remarks that "from 1700 to 1750 the deaths from consumption increased from four to six in every thousand of the population," and that since the last period they have remained stationary. But in coming to the conclusion that this disease has increased, he must surely be aware that he has selected, as a period of comparison with subsequent dates, one when the number of consumptive cases was singularly low. Had he gone back for a few years, he would have found the number of phthisical cases averaging one-fifth of the whole, and in 1687 they were, as at the present time, one-sixth.

Dr. Heberden states that consumption was on the increase in the eighteenth century, which certainly is indisputable, as the table I have con-

c2 structed shews; but if his object was to prove, from former changes, whether or not the disease was likely to become more or less frequent, he, like Sir James Clark, made a most unfortunate selection as to time, and affords an instance of the errors we are liable to fall into by restricted observation. I shall, however, give his observations on the period he refers to. He says, " The following statement was deduced, in a coarse manner, from an average of about ten years, for the purpose of comparing, generally, the mortality occasioned by certain diseases, at the beginning, middle, and end of the eighteenth century, care being taken, in each period, to select such years, in which the whole number of deaths was nearly the same, namely, about twenty-one thousand."* In regard to consumption, his table exhibits the following statement for these three specified divisions of the eighteenth century : —

BEGINNING.

MIDDLE.

END.

* Heberden, Jun., Observations on the Increase and Decreaseof Different Diseases. London, 1801.

These illustrations, it must be observed, are restricted to the metropolis, and we have no documents from which we can draw any conclusions as to the increase or decrease of consumption throughout the whole of Great Britain.

From my own personal observation, as well as from the statements made to me by many practitioners, in various parts of the country, both in England and Scotland, I am inclined to believe, and, in fact, entertain no doubt, but that during the last ten years the disease has increased among some ranks of society, while it has decreased among others. On the whole, therefore, we may reasonably infer, that although London does not now lose so great a proportion of her inhabitants by this scourge, nevertheless the general mortality occasioned by it, throughout the kingdom, seems to continue unabated.

Part III

CONSUMPTION BEING ON THE INCREASE AMONG SOME CLASSES OF SOCIETY, WHAT RANK, IF PARTIAL, DOES IT CHIEFLY ASSAIL ?

This is a question which it would be impossible to solve by means of official reports, for the Re.

gistrar-General does not, of course, specify what number of phthisical cases belongs to each of the artificial grades into which society has been divided. The united observations of professional men, or an annual statement from the local Registrars on this subject, can alone settle it. As far as my own experience goes, I am disposed to think that the partial increase of consumption has chiefly occurred in the upper classes of society, and more especially among females ; while among the lower classes the malady seems to have become less frequent. This may, perhaps, be accounted for by taking into consideration the greater comfort now enjoyed by labourers and the poor, which classes constitute so great a proportion of the population ; while the rich, to gratify the morbid fancies of the age, indulge more and more in pernicious and unnatural luxuries, which gradually produce a tendency to disease. We see that this malady is not even heard of among some nations, where the arts of refinement and the luxurious practices of civilised life have not as yet obtained a footing. Dr. Benjamin Rush, of Philadelphia, speaking of pulmonary consumption, says, it is " unknown among the Indians of North America."* Sydenham remarked, that acute diseases come from God, but chronic diseases originate with ourselves, or, to use his own words, " Morbi acuti Deum habent autorem, chronici ipsos nos."

Sir James Clark's opinion is so far confirmatory of mine, as to the partial change which has taken place, in regard to the increase of phthisis among the wealthy. He says, "Whether tuberculous diseases have diminished or not during the last half century among the labouring part of our population, I am of opinion that they have increased in the middle and upper ranks. "f

Part IV. Influence Of Climate On Pulmonary Consumption

In treating this part of the subject, we must, in the first place, consider the influence of climate in producing the disease ; and, secondly, its influence in exciting the malady in those predisposed, as also its effects on consumption already existing.

An opinion has been very generally entertained,

* Medical Inquiries and Observations, by B. Rush, M.D., vol. i. p 159. t Treatise on Pulmonary Consumption, by Sir James Clark, M.D., p. 10.

that certain - climates will produce pulmonary consumption ; and an attempt has been made to discover, by reference to the statistical reports of Great Britain, and, by contrasting this nation with other countries, some evidence of a regular and universal law on the subject. Although such result was anticipated, and although industry and talent have conjointly embarked in this voyage of discovery, still the result has been extremely unsatisfactory. Sir James Clark observes, that " the facts relating to the prevalence of consumption in different nations, which I have been able to collect from their statistical documents, are so discrepant, that no positive conclusion can be drawn from them to shew the influence of climate in producing the tubercular diathesis." * Another author says, in reference to the influence of climate on this disease, that, " on no subject has more been written, or less satisfactory information been obtained."!