Part 1

AN

Inaugural Dissertation

ON

PULMONARY CONSUMPTION.

BY EDWARD DELAFIELD, A. B.

----For want of timely care, Millions have died of medicable wounds. ARMSTRONG.

_NEW-YORK_:

PRINTED BY JOHN FORBES & CO. 78 WALL-STREET.

1816.

TO

SAMUEL BORROWE, M. D.

ONE OF THE SURGEONS OF THE NEW-YORK HOSPITAL,

THIS DISSERTATION

IS DEDICATED,

AS A TESTIMONY OF GRATITUDE

FOR THE MANY VALUABLE PRACTICAL LESSONS

RECEIVED FROM HIM

BY HIS FRIEND AND PUPIL,

EDWARD DELAFIELD.

INTRODUCTION.

The attention of Physicians has for several years past been excited to the consideration of that inveterate enemy of the human race, the CONSUMPTION. Several works have been published, new remedies proposed, and the practice of former physicians revived with modifications and amendments, in the treatment of this disease. At one period, Consumption had been so long considered without the reach of remedies, that it had almost ceased to excite the enquiries of the learned in medicine. Fortunately, however, the spirit of enquiry has revived; and it is believed that the treatment of this dreadful malady has been so far improved, that many are rescued from its grasp, and the sufferings of those who are still its victims, are materially mitigated. Notwithstanding, it appears that in this city the mortality from Consumption has increased rapidly of late years. Formerly, its climate was considered remarkably salubrious, and diseases of the lungs were rare. Lieutenant Governor Colden, in a series of remarks on the climate and diseases of New-York, made seventy years ago, has the following observations: “The air of the country being almost always clear, and its spring strong, we have few consumptions or diseases of the lungs. People inclined to be consumptive in England, are often perfectly cured by our fine air; but if there be ulcers formed, they die. The climate grows every day better, as the country is cleared of the woods; and more healthy, as all the people that have lived long here testify. This has even been sensible to me, though I have lived but about twelve years in this country; I therefore doubt not but it will in time, become one of the most agreeable and healthy climates on the face of the earth.”[1]

These anticipations have not been realized; but, on the contrary, Consumption has become the prevailing disease of our city. The causes of this increase of the disease are numerous. We are told by Dr. Rush, that it is unknown among the Indians of North America; that it is scarcely known by those citizens of the United States who live in the first stage of civilized life, and are generally called the first settlers; that it is less common in country places than in cities, and increases in both, with intemperance and sedentary modes of life; that ship and house-carpenters, smiths, and all those artificers, whose business requires great exertion of strength in the open air, in all seasons of the year, are less subject to this disease than men who work under cover, and at occupations which do not require the constant action of their lungs. By applying these facts to the situation of this city, the causes which have produced the increased mortality from consumption, become evident.

1. The growth of the city, and consequent state of the atmosphere, most distant from that of the pure air of the country.

2. The increase of all those causes which have enervated the bodies of men, and rendered them more susceptible to the influence of a variable climate. Among these are, augmentation of wealth, and consequently, luxury; increased dissipation, with its accompaniment, imprudence in dress; and extension of manufactures, affording greater opportunity for sedentary employments, and exposure to an insalubrious atmosphere. In general, the causes are, all those circumstances which tend to remove man farthest from that situation, in which the body is possessed of the greatest vigour, and of course, least subject to disease, that of the savage. In proportion as the city has enlarged, these causes have continued to increase, and probably still will do so. But in Great Britain, they appear already to have attained their acme, and as a consequence of the improvements in medicine, the causes not increasing, the disease is on the decline.[2]

The following statement will show the proportion, which the number of those who die from consumption, bears to the whole number of deaths, in this city, during the last twelve years.

In 1804, 499 persons died from Consumption, and were to the whole number of deaths, 2125 as 1 to 4.25.

In 1805 462 2352 1 5.09 1806 354 2225 1 6.28 1807 464 2312 1 4.94 1808 429 2014 1 4.69 1809 413 2108 1 5.1 1810 569 2158 1 3.79 1811 595 2524 1 4.24 1812 669 2553 1 3.81 1813 562 2229 1 3.96 1814 618 2507 1 4.04 1815 572 1974 1 3.8

From this statement it appears, that the number of deaths from Consumption has gradually increased. The average proportion during the period mentioned, is as 1 to 4.36. Nearly one fourth of all those who die in this city are destroyed by this fatal disease.

These facts prove indeed that the power of medicine has little control over so destructive a malady. But it should not therefore paralyse our exertions. From what has been done already, in improving our knowledge of its nature and treatment, a hope may be indulged that consumption may one day, like many other maladies formerly deemed incurable, be placed no longer among that number.

INAUGURAL DISSERTATION

ON

PULMONARY CONSUMPTION.

The term Phthisis, or Consumption, in its broadest sense, is applied to all those diseases, in which the system sinks under a gradual waste of the powers of life. These diseases may be divided into two great classes--1. That form of Consumption in which the lungs are unaffected.--2. Phthisis Pulmonalis, properly so called, where the lungs are the seat of the disease.

Under the first class are included,

1. Atrophia, or Consumption from want of nourishment, or excessive evacuations, but without hectic fever; excluding all those forms of disease produced by immoderate evacuations, in which the lungs become affected.

2. Tabes, accompanied with hectic fever, frequently attended with disease of the mesenteric glands, and produced most commonly by scrophula.

The second class, Phthisis Pulmonalis, to the consideration of which this essay will be more immediately confined, may be also subdivided into,

1. Primary, where the lungs are the original seat of the disease, and as a consequence, the general system becomes affected.

2. Secondary, where the system being first reduced by any debilitating cause, the lungs become secondarily affected, as a symptom of the general disease.

These two forms of Consumption, although somewhat similar in their symptoms, yet proceed from opposite causes, and require opposite treatment. The one is a disease of pure inflammation; the other of unmixed debility. In the one, an active antiphlogistic treatment is necessary; in the other, the system requires all the support, which tonics and good nourishment can afford.

Phthisis Pulmonalis is thus defined by Dr. Cullen, “_Corporis emaciatio et debilitas, cum tussi, febre hectica, et expectoratione purulenta_.” This definition is peculiarly incorrect, because it leads us to neglect, the first stage of the disease; if the symptoms of an Incipient Phthisis were stated to us, and we were asked, what was the disease, from this definition we would be perfectly at a loss for an answer. Except the cough, none of the symptoms there stated are to be found in the first stage of Consumption. And yet that is as truly a part of it, and of as much importance to the practitioner, as the last stage, which alone is included in Cullen’s definition.[3]

Agreeably to this definition, in his view of Phthisis Pulmonalis, Dr. Cullen makes ulceration of the lungs and hectic fever essential to its existence, and seems rather to consider the preceding symptoms a cause of this ulceration and fever, than as constituting an integrant part of the disease.

Nor is the place assigned by him to Phthisis Pulmonalis, in his Nosological Arrangement, more correct than his definition of it. He places it in the order Hæmorrhagiæ, and considers it merely as a consequence of Hæmoptysis. Even if it were always excited by hæmorrhage from the lungs, it would be improperly thus placed; but as that, even by Dr. Cullen, is considered merely as one among many exciting causes, the arrangement is altogether inadmissible. But if it be admitted, according to the view which will be hereafter taken of Hæmoptysis in this treatise, that it is rather a symptom than a cause of Consumption, the propriety of another arrangement will be evident. Accordingly Phthisis Pulmonalis is placed by Dr. Hosack, as one of the Phlegmasiæ. This disposition appears to be the most proper that has hitherto been suggested, and as such I shall adopt it. But before we can ascertain the character and treatment of any diseases, it is necessary minutely to examine their causes and symptoms.

Primary Phthisis Pulmonalis first claims our attention. Its predisposing causes may be mostly arranged into five classes, as they depend on organization, age, sex, occupation and climate.

Organization predisposes to Consumption, by mal-conformation of the chest, which may be either natural or accidental; and an hereditary internal structure not depending on the external form of the thorax. For it is observed, that in some instances, those who have every part of the external configuration, such as is generally attributed to persons predisposed to Consumption, yet shall be free from this disease; while on the other hand, some whose chests are externally perfectly well formed, have been subject to catarrhal and inflammatory complaints of the lungs, terminating in Phthisis. The form of chest peculiar to many Phthisical patients, “is occasioned by the sternal or breast-bone being pressed too much in upon the substance of the lungs: thus the clavicles and shoulder-blades are thrust out of their proper position, and made to assume, in some measure, the form of wings, to which indeed they have been with propriety compared, just raised from the body and about to expand for flight. By this internal direction of the sternum, the full expansion and proper sweep of the ribs is likewise prevented, and an unnatural curvature or prominence is occasioned on either side of the breast, with a corresponding central depression.”[4] This is the peculiar form to which the term narrow chest is generally applied. A flattened or any other unnatural figure of the chest may produce the same injury.

The thorax may become accidentally malformed from any violence done to it, particularly during infancy. A frequent source of it is the mode of fashionable dress adopted by females. The corset, to which I allude, when worn only with moderate firmness, and by those not otherwise predisposed to Phthisis, serves but to add elegance and beauty to the female figure; but when applied with the object of converting into a delicate and slender waist, one naturally otherwise, it cannot but do injury. By immoderate pressure, it converts a well formed chest into the deformed and narrow one, or at least an approximation to it, which has just been described. In our own city and time, too many fatal examples of the deleterious effects of this fashion have occurred, to permit us to retain any doubts on the subject.

The internal constitution of the body predisposing to Phthisis, independent of external form, has been generally attributed to scrophula. English authors are particularly fond of making Consumption another form of that Protæan disease. We are much disinclined to concur in this opinion from the fact, that the mass of those who labour under the disease in question, and cases too, which, after death show that tuberculated state of the lungs, generally ascribed to scrophula, evince no other of the numerous symptoms of that disorder. The supposition that tubercles were scrophulous, probably originated from the opinion that they are diseased glands; an idea now sufficiently exploded. This hereditary predisposition we know to exist, but of its mode of action we are totally ignorant. In this city there are many melancholy examples of whole families successively falling victims to Consumption, and sufficiently proving its hereditary nature. But an hereditary predisposition does not necessarily produce Consumption. It is not uncommon for parents who inherit this taint, to remain free from disease of the lungs, by the pursuit of laborious occupations. Nor is it more uncommon that the children of these very parents, whose active industry had preserved their lives, and amassed them wealth, should by being enabled to indulge in ease and luxury, fall victims to an inherited Consumption.

So the females of a family are sometimes all consumptive, while the males are free from pulmonary disease, in consequence of the more sedentary mode of life of the former.

Although no period of life, from infancy to old age, is exempt from Consumption, but all are liable to its attack, yet at a particular age, it is observed to appear more frequently than at any other. This period commences about, or soon after the age of puberty, and terminates at thirty-six; the period at which inflammatory diseases most generally occur.

Sex also gives a predisposition to Consumption. Females are more frequently affected by it than males. This may be attributed to their greater delicacy of constitution, and nervous temperament. Their comparatively sedentary habits of life add to this peculiar constitution. But improper compliance with the requisitions of fashion and taste constitutes not a small part of the greater susceptibility of females to Phthisis. Independent of the use of corsets, the small quantity of clothing frequently worn by them, under circumstances when it is most necessary, is a fruitful source of mischief to their health. In the coldest of our winter nights, will these fair devotees of fashion issue from rooms, heated to a degree never experienced in our hottest weather, into the chilling air of midnight, with less clothing than they use at noon, when the sun exerts his greatest power. The next day brings with it “a violent cold,” and this cold is too frequently the foundation of the Consumption which destroys them.

Occupation in life is another source of the ravages of this disease. Particular occupations subject those engaged in them to the respiration of air impregnated with foreign materials, irritating the lungs, either by their chemical or mechanical action. Substances acting mechanically upon the lungs, are inhaled by stone-cutters, millers, hair-dressers, bolters, coal-heavers, scythe-grinders, persons engaged in pointing needles, chimney-sweepers, dressers of flax and feathers, spinners in wool, and others employed in similar occupations. Chemical agents are taken into the lungs by manufacturers of acids, and all other volatile corroding substances. These materials constantly acting upon the lungs, produce irritation and slight inflammation, terminating in Phthisis. The operation of any of these causes is favoured when the occupation requires a stooping or other awkward posture of the body to be maintained. This cause may act independently of the former also, and hence, students, and clerks writing at their desks, taylors, shoemakers, &c. are liable to this disease. To the same causes are frequently added, a sedentary life, and confinement in hot rooms; hence “a surgeon of London whose opportunities of observation are very extensive, relates of the gilders of that city, who work in heated rooms, that six out of seven are said to die consumptive in their apprenticeship.” Sedentary habits of life, accompanied with hard study, and too intense application of mind, predispose literary men to Consumption. Loud public speaking, blowing on wind instruments, glass blowing and other circumstances requiring a laborious and continued action of the lungs, produce the same effect. Any one of these causes may frequently exist without injury, but their combined action seldom fails to produce pulmonary disease.

Climate was enumerated under the predisposing causes of Phthisis. That of our own latitude affords an example. Its variableness, increased by contiguity to the ocean, together with the prevalence of the moist and chilling north-east winds, is probably the agent which produces this effect. The climate of Great Britain is not less unfavourable to health, from similar causes, with the addition of its greater moisture; for it is observed that cold combined with moisture is peculiarly dangerous to the consumptive. On the other hand, inland countries, not exposed to the moist winds from the ocean, are free from this disease. Hence, the inhabitants of Russia and other parts of the north of Europe, notwithstanding the severity of their climate, are very little affected by Consumption. The habits of the people, probably assist in producing this immunity from pulmonary disease. Sir John Sinclair, in a communication to Dr. Reid, attributes it in a great measure to the employment of furs, cloaks and other modes of clothing, which preserve an uniformity of warmth throughout the body; to the great care taken by all classes of people to preserve their feet from cold and damp; to the different modes of communicating heat to their apartments; and to the constant use of the vapour bath. Similar observations were made by Dr. Cogan, who in a letter to Dr. Beddoes, remarks that the people of Holland are exempt in a great degree from this disease, so prevalent among the English, and ascribes the difference to the contrast observable between the two countries, in the construction of their habitations, and in the peculiarities of dress.

Debility from the want of accustomed stimuli, is mentioned by Dr. Hosack as another cause of consumption, and he instances those confined in the State Prison. The want of accustomed air and exercise, the deprivation of the use of spirituous liquors and good diet, to which the prisoners had been accustomed before their confinement, was observed by him to have produced this disease.

Depressing passions of the mind, and a consequent too free use of spirituous liquors have also been noticed by authors among the predisposing causes of Consumption.

The last of these causes which I shall notice, is the disposition of the system to form calculous deposits in the lungs, generally in consequence of a plethoric habit. Phthisis from this cause however is rare; of nine hundred patients examined by Bayle, only four were of this description.

These various causes having either separately or conjointly predisposed the body to Phthisis, are most frequently excited into action by a common catarrh; which becomes the more active by frequent repetition. The danger arising from catarrh is not a little increased by the popular mode of treating it: stimulating spirituous drinks, and a vast variety of remedies of the same class are the usual prescriptions. Almost every body has an infallible remedy for a cold; some of them innocent, but many injurious. The common prejudice in favour of “feeding a cold” increases the mischief, and unfortunately, the disease not generally affecting the system sufficiently to destroy the appetite, as in many other maladies, nature does not prevent the practice. Abstinence, cooling acidulous drinks, with perhaps a gentle saline cathartic, are the safest and most effectual remedies in curing a common catarrh, when of its usual slight form. At the same time, inhaling warm air, by means of Mudge’s apparatus, is a valuable and grateful auxiliary to this treatment. Catarrh is so common and generally so easily cured without any consequent ill effects, that it is too apt to be neglected. Many a patient, labouring under incipient Phthisis, has been supposed to be affected by merely a “trifling cold,” and the only opportunity for curing the disease has been lost. “The evil becomes irremediable before it calls either the attention of the parents, the friends, or even the physician, who has not been familiarly conversant with the fatal consequences of this disease.”[5]

Pneumonia is not unfrequently an exciting cause of Phthisis. Like catarrh, its frequent repetition is more dangerous than a single attack. Pneumonia may indeed act merely as a predisposing cause of Consumption, by leaving the lungs in a debilitated and irritable condition, favourable to the production of that disease; but it is an exciting cause, when in consequence of inflammation of the lungs, suppuration follows, and vomica or empyema is the consequence. This shews the close analogy between Phthisis Pulmonalis and ordinary Pneumonia. In the first, the inflammation being seated in the cellular and comparatively insensible portion of the lungs, is slow and gradual, and the consequent suppuration forms in the same manner; while in Pneumonia, the membranous as well as cellular portion of the lungs being involved in the disease, the inflammation is rapid and violent, and must soon terminate in either resolution or suppuration. Hence Phthisis Pulmonalis was appropriately called by Dr. Rush a “_Pneumonicula_.” No word could more accurately describe the nature of the disease. That acute observer has drawn an excellent parallel between the two diseases, and concludes with observing, “In short the pneumony and Consumption are alike in so many particulars, that they appear to resemble shadows of the same substance. They differ only as the protracted shadow of the evening does from that of the noon-day sun.” It is remarked, however, that all cases of Pneumonia terminating in suppuration are not necessarily fatal. If a predisposition to Phthisis do not exist, or the constitution be not too much debilitated, a vomica may burst and be discharged, and the patient recover.

A third exciting cause of Phthisis, is the suppression of accustomed evacuations. These evacuations are the menses, the lochiae, the discharges in Leucorrhæa, and from ulcers, fistulæ and issues. Retention of the menses producing Chlorosis, being a consequence of debility, does not excite primary Phthisis Pulmonalis, but the secondary form of the disease. Suppression of the menses, however, not unfrequently excites a Consumption, bearing all the characters and requiring the treatment of primary Phthisis. The plethora, consequent on the cessation of the menses, has often the same effect.

Asthma, by the constant irritation to which it subjects the lungs, becomes an exciting cause of Consumption.

Several eruptive diseases, as Scarlatina, Small-Pox and measles, often produce the same disease.

Morton also enumerates stone in the kidneys and bladder, gout and rheumatism, as causes of Consumption.

By the same author, contagion is supposed to communicate this disease. Morgagni, Van Swieten, Home and Heberden all hold this opinion. And Morgagni relates that Valsalva, who was predisposed to Consumption, was so satisfied of its contagious nature, that he constantly avoided being present at the dissection of the lungs of persons who had died of that disorder.