SIJGQYBSTIONB 
RELATIVE TO THE 
PATHOLOGY OF PNEUMONIA. 
S.JO. VANDEBPOEL, M. D., ALBANY, N. Y. 
[Reprinted from the Transactions of the Medical Society of the State of New York, for 1865.] 
ALBANY, N. Y.: 
VAN BENTHUYSEN’S STEAM PRINTING HOUSE. 
1865. [Reprinted from the Transactions of the Medical Society of the State of New York, for 1865.] 
SUGGESTIONS RELATIVE TO THE PATHOLOGY OF 
PNEUMONIA. 
BY S. 0. YANDEBPOEL, M. D., ALBANY, N. Y. 
The opinion very prevalent in the profession, and consequently 
among the community, that pneumonia is induced solely hy expo- 
sure to cold, or to sudden variations of temperature, has, we think, 
a pernicious influence upon the treatment, based as it is upon a wrong- 
pathology. 
That pneumonia is excited by causes more intimately connected 
with the healthy workings of the system than mere exposure to cold, 
we think is plainly evident; else why will the same person at one 
time undergo prolonged exposure and experience no ill effects, 
while at another, comparatively slight, he is stricken with the ma- 
lady ; or why are A. and B. apparently equally endowed with the 
capacity to resist morbid influences, and yet when equally exposed 
to variations of temperature, the one has pneumonia while the other 
escapes. 
One of the first things which strikes us in looking at the subject 
from this stand-point, is the relation of pneumonia with certain dia- 
theses, and with traumatic diseases subjected to an infected atmos- 
phere. These diatheses are intimately connected with the circula- 
tion of morbid or poisoned materials in the blood which fail to be 
eliminated by the proper excretory organs, or to the direct inhala- 
tion of a vitiated atmosphere. This latter condition has been fre- 
qnently noticed in large army hospitals, where proper hygienic pre- 
cautions are not taken. In a limited experience we have observed 
case after case dying from pneumonia, while the wound was appa- 
rently progressing favorably, where the external atmosphere was 
bland, but where from imperfect ventilation, or the great mass of 
suppurating wounds, the air in the wards was tainted with decom- 
posing effluvia. 
Our opinion therefore is, that pneumonia cannot result alone from 
exposure to cold, no matter how prolonged and intense; but that 
co-existing with this exposure there must be morbid materials circu- 
lating in the system which, acting on the sentient fibres of nerves 
that supply the air vesicles, partially paralyze them, and permit a 
change of temperature or any irritant cause to produce the pheno- 
mena of inflammation and its attending sequences. Further, that in 
pneumonia two phases of disease are presented, the one wholly dis- 2 
tinct from the other. In the first stage, lasting from four to seven 
days, it is the system struggling to eliminate or cast off the 
poisoned material—a stage always attended by the most acute symp- 
toms and violent arterial reaction, the close of which is marked by a 
decided abatement in all the constitutional symptoms, and an exuda- 
tion into the air-vesicles called hepatization. From this point begins 
the lung disease proper, and whatever of subsequent constitutional 
symptoms ensue, arise from efforts to relieve the solidified air-vesi- 
cles of their foreign material. 
Perhaps this will be better appreciated by following the natural 
history of a case of simple pneumonia. First, the course of the fever 
as measured by the thermometer and the pulse, dating the onset of 
the disease from the shivering, we usually find on the third day an 
active febrile condition, with flushed cheeks, constant cough, viscid 
bloody expectoration, hurried breathing with crepitation and the 
commencement of bronchial respiration at the base of the lung. 
During the third, fourth and fifth days the temperature is uniformly 
high, rising from 98° as a normal standard, to 104°-106°, and with 
slight alternations of 1° and 2°, between morning and evening, main- 
taining this temperature until some time on the sixth day, when a 
rapid fall takes place, so that some time during the seventh it marks 
but 98°, the normal standard. The pulse follows closely the increase 
of temperature, rising to 100°, to 120°, and about the sixth day fall- 
ing to 90°, 80°-70°. Respiration rises to about 40°, and does not 
decrease in proportion to the heat and pulse. 
Second. The course of the local lung symptoms—crepitation— 
becomes less, while the bronchial respiration increases, with the in- 
creasing hepatization. This reaches its maximum about the sixth 
day, when a crisis occurs, a sudden and rapid defervescence, usually 
accompanied by a strong action of some eliminating organ, such as 
the skin, the kidneys or the bowels. The sputa, which are most 
bloody on the third and fourth days, become more rusty on the fifth 
and sixth, after which they are less viscid and become free from 
blood or hsematine. After the seventh and eighth days the bron- 
chial respiration begins to lessen and ceases from the twelfth to the 
sixteenth day. From this casual and rapid description, it is seen 
that the crisis occurs, with a rapid and marked diminution of the 
constitutional symptoms, at the very time when the lung trouble— 
the hepatization—is at its height, and when, if we suppose mere in- 
flammation of this tissue constituted the disease, there would be the 
most decided evidence of constitutional disturbance. Rather do we 
suppose, that with the elimination of the blood poison from the 
economy into the air-vesicles, the active disturbance ceases, when the 
depurating organs quietly convey it from the economy. 3 
We propose to present our considerations for this belief under the 
heads of crisis, diathesis—the action of eliminating organs and treat- 
ment. 
From the earliest period of medicine the word crisis has been 
associated with the idea of elimination; as if the system had been 
striving to free itself from some foreign material acting banefully 
upon the whole organism. Of course among the ancients the idea 
underwent many fanciful changes, but this was the inherent principle. 
We now understand by the word, a change for the most part favor- 
able, which arises in the course of a disease, announced by some 
particular phenomenon, as an abundant excretion, either by hemor- 
rhage, sweating, or deposite in the urine; and at the same time a 
marked subsidence in all the constitutional symptoms. The term is 
rarely applied to local inflammation of organs or tissues, but rather 
to those conditions of the general system where the fluids seem 
poisoned, or impressed by some deleterious material which nature is 
struggling to cast off. Such is the case in the different forms of 
malarial and typhus fevers, and in those peculiar conditions of the 
system, represented by the diatheses, and which we term the strum- 
ous, gouty, rheumatic, &c. The expression “favorable crisis” in any 
of these affections, is synonymous with some decisive eliminative act. 
Whatever of subsequent sickness occurs in the disease, arises from 
incidental causes, or injury to some organ affected by the eliminative 
process. Applying this to pneumonia, we contend that the sickness 
up to the fifth or seventh is this struggle for elimination; which when 
completed a decided crisis occurs, marked by an abatement, indeed 
in most cases, by a decided subsidence of all general symptoms. Not 
those however of a local character, as the respirations remain near 
forty, and hepatization is then complete. It docs not invalidate this 
position to ask, why the peculiar poison in pneumonia should seek 
the lungs. We know them to be one of the three great eliminative 
O C? 
organs in the economy, and we recognize daily, how seriously the 
other two, the skin and kidneys are affected when by the presence of 
some foreign element their excretory functions are impaired. Dr. 
Parkes the able clinical lecturer at Edinburgh in relation to this 
point, says; “The only blood disease which has yet been indicated 
by the supporters of this view, as anterior to pneumonia is hyperi- 
nosis (excess of fibrin), and as hyperinosis occurs in rheumatism with- 
out pneumonia, it is evident that there must be some other cause, 
either in the blood, or in the local structure of the lung, which locates 
the disease in that part. Now hyperinosis is really anterior in pneu- 
monia as in rheumatism; that it is not however the only condition 
will be generally admitted. But what other blood affection is there ? 4 
None Inis yet been indicated to my knowledge in the acute sthenic 
pneumonia of young persons without gouty or renal disease. But 
there is one point on which I have been trying to collect evidence 
for some years, but at present without sufficient success. It is well 
known how frequently the liver is affected in pneumonia, so that 
some amount of jaundice is not at all uncommon, and sometimes bile 
pigment appears in the pneumonic sputa. I have also found in some 
cases evidence of liver affection for some time before the lung: disease 
especially the so called torpor with deficient biliary flow. Is there 
then any condition of the liver which adds something to the blood 
which ought not to be there ? Taurin has been found in the healthy 
tissue of the lung; but in the hepatized lung, it seems from Yerdeil’s 
observations to be in excess. Is it some compound of this sort which 
in combination with the hyperinosis, determines the localization of 
the blood disease, or produces by its irritation the inflammation of 
the lung ? 
Diathesis.—In 'giving the natural history of diseases, writers too 
often fail to recognize the influence of diathesis ; while in practice it 
is one of the most important elements to consider. It is this idea, 
to which laymen unconsciously attach so much importance when they 
say of the physician “he understands my constitution.’7 These “ per- 
sonal peculiarities’7 the careful physician must recognize in practice, 
oftentimes assuming prominence, far greater to the vital relations 
than the peculiar malady under which the patient suffers. The sys- 
tem thus stamped with a “peculiarity” or diathesis, tends to the 
repeated expression of some form of ill health, always in the same 
way. They arc by no means limited to the individual, but are trans- 
mitted from parent to offspring, and thus become hereditary. Not 
traceable to the extrinsic action of a virus, and with none of the pro- 
perties attached to infection, they arc apparently generated, devel- 
oped, and sustained under the influence of an intrinsic blood-poison: 
the result of perversion of the nutritive or assimilative functions of 
the individual. Dr. Walsh thinks “each member of the group has 
its specific morbid principle in the blood, uninterchangeable with the 
rest, just as any one virus is uninterchangeable with others.77 It is 
only necessary to name the rheumatic, gouty, strumous, and syphi- 
litic as the conditions indicated in their respective diatheses. True 
other divisions of a more general character are at times made by the 
surgeon, and which are really of vital importance from his stand- 
point; as the plastic and aplastic diatheses; but our present argument 
has only to do with the former, which are inherent and constitutional, 
and not with the latter, which are more or less acquired and accidental. 
Now, it is we believe an admitted clinical fact, that pneumonia in 
the great majority of cases, appears in persons laboring under one or 5 
the other of these diatheses. We recognize also in such constitutions, 
the importance of a free action of the eliminative organs, and how 
soon the respective diatheses become apparent, if the functions of 
either of these organs are impaired. When the poison seeks the kid- 
neys for an outlet, suffer though they may in their function, yet their 
tissue less delicate, and less essential to the vital organization than 
the pulmonary does not manifest itself by as active local symptoms, 
or when defervescence occurs entail secondary lesions, which call for 
new efforts of the economy to restore. The same is also true when 
the functions of the skin arc temporarily impaired. 
It does not invalidate the theory of a blood-poison as a latent cause 
of pneumonia, to state that its immediate determination to the lungs 
may be owing, either to the depressing influence from exposure to 
cold, or as in an infected hospital to a poisoned atmosphere acting on 
sentient libres, weakened in vitality from its influence; in the latter 
case, an acquired diathesis, the aplastic, supervening. 
If the lungs were the only organ implicated in an attack of pneu- 
monia, there would be strong ground for regarding it a simple, idio- 
pathic inflammation, but we shall see that in addition to the predispos- 
ing influence of diathesis, both the kidneys and skin are seriously 
impaired in function, and that the signal for their return to a normal 
condition, is the completion of the eliminative process, corresponding 
to hepatization of the lung. The amount of water secreted by the 
kidneys, is lessened from one-third to one-half; while that of urea 
is greatly increased during the height of the disease. These changes 
O O O O 
are easily accountable from the general febrile condition ; the former 
being always retained in fever, and the latter marking the metamor- 
phosis of tissue resulting from it. The feature peculiar to pneumo- 
nia, is the great diminution, or even entire absence of chlorate of 
sodium from the urine, during the existence of the fever and the 
process of hepatization. Even when administered by the month it 
does not appear ; nor does it re-appear until the process of resolu- 
tion is established. Albumen is present in the urine, in a large pro- 
portion of the cases, most common at the height of the disease. It 
cannot be ascribed to absorbed exudation, appearing as it docs 
chiefly before resolution ; but rather to the implication of the kidneys 
in the general congestion and exudation ; the most marked local seat 
of which is the lungs. “ One conclusion may certainly be inferred, 
namely, that the disease of which we are speaking involves profound 
changes in the chemistry of life.” 
Finally—the relations of treatment-—of no disease has there been 
such extreme and radical views of treatment, as a single decade has 
witnessed with reference to pneumonia. From the heroic “ coup, 6 
sur coup” bleeding of Bond land, or the large doses of antimony by 
other practitioners, to the earnest advocates of a purely expectant 
treatment we have presented every shade of doctrine and theory. 
This great contrariety of opinion shows at least, widely different 
views of pathology, since upon our notions of this latter must all 
treatment be based. It points also significantly to the fact, that these 
views are far from being fixed. Experience tells us wherever the 
pathology of a disease is definitely settled, the treatment is at once 
simple and uniform. 
Bouilland regarding pneumonia strictly as a local inflammation would 
jugulate it, suppressing every effort of arterial re-action by deple- 
tion. Those who pursue an expectant course but follow out the self- 
limiting theory in the duration of disease. Statistics, imperfect as 
they are, decidedly favor the latter as preferable of the two extremes. 
Pneumonia cannot be jugulated by depletion, any more than can a 
case of acute rheumatism. As in rheumatism the severity of the 
symptoms may be mitigated, still the mortification is experienced of 
seeing it prolonged into a chronic stage ; so in pneumonia, depletion 
is far more apt to retard than aid the evolution of the subsequent 
stages of the malady. On the other hand, the advocates of a purely 
expectant treatment abandon themselves to a blind fatalism, in which 
all diatheses, and all conditions of vitality have but the one recupe- 
rative agency—nature. We are not of those who favor either party 
in their extreme views. While on the one hand there are cases in 
which the hypersemia is so intense as to cause great pain and dysp- 
noea : to relieve which a moderate bleeding is beneficial ; there are 
others, where no treatment save proper hygienic measures and diet 
are necessary for the cure. Unfortunately the latter class of cases, 
typical in their character, are comparatively rare. Pneumonia is a 
disease, Avhere in a peculiar manner, the diathesis and vital powers are 
to be studied ; for while in all we strive to aid nature in the elimi- 
native process, we quite as frequently find it necessary, even in the 
early stage, to sustain by stimulants and tonics, as in the stronger 
vitality, temporarily to depress. The crisis once developed, hepati- 
zation completed, no one will question the propriety of sustaining 
the economy, for the more perfect elimination of the morbid material. 
It would be an interesting study to show how unsatisfactory the 
generally received notions ot the pathology of pneumonia are to the 
most intelligent writers of the clay. Struggling as it were for some 
stand-point by which it could be classed among diseases of a specific 
character, Todd in his clinical lectures points to this idea of a mor- 
bid material seeking elimination—if you watch the changes which 
a patient in pneumonia undergoes in his progress towards convales- 7 
cence, you will find more or less sweating always takes place. 
Sometimes the sweating occurs freely, and it is then considered criti- 
cal. Sometimes too a critical discharge of purulent matter from the 
lung takes place by expectoration ; now and then the kidneys about 
this time secrete much more urine than previously ; and occasionally, 
though certainly very rarely a critical diarrhoea occurs. Always 
chloride of sodium begins to escape from the system through the 
urine, from which during the height of the disease it had been ex- 
cluded. All this looks as if something, which caused the morbid 
change in the lung were eliminated from the system in one or more 
of the secretions ; and therefore to promote these should be the aim 
of our treatment.” 
We close with the more direct propositions of Dr. Parkes, sum- 
ming up as they do fully, the views we have ventured to elaborate 
in this paper. “Pneumonia is a blood disease of some sort, of a 
nature not thoroughly known, but which consists, in part, in an aug- 
mentation of the fibrin, as in acute rheumatism. Increasing up to a 
certain point, and giving rise to the slight malaise which precedes all 
cases of pneumonia it is at last brought to a head by some exposure, 
by a dietetic error, or by reaching a point at Avhich the functions of 
the blood are seriously interfered with. Then ensues high general 
fever, from implication of the nervous system, and at the same time 
some organ or other is, on account of special affinity for the morbid 
blood, or from previous damage to its structure specially irritated. 
In pneumonia, the lung is the seat of election, and there is rapid 
hypcrcemia, and transudation of fluid into the air-cells. By this 
transudation the morbid blood is purified. The process is analogous 
to that of gout, in which a diseased blood gives rise to a local dis- 
ease by the deposition of urate of soda in and about joints. When 
the localization and consequent purification is finished then the fever 
ends. There remains the lung exudation, which gradually softens 
down, is partly expectorated, partly absorbed ; and in the process 
of absorption, it may produce again secondary contamination of the 
blood, and certain affections of other organs, which constitute those 
secondary affections which sometimes complicate the after course of 
pneumonia.”