Dn. GORDON on Pneumonia. 95

ART. X.qClinieal Observations on Pneumonia, and its Treat- ment by Sulphate of Quina. By SAMUEL GORDOn, M.B., F. R. C. S.L, M . R . I . A . , Physician to the Whitworth and Hardwicke Hospitals, Examiner in Medicine to the Queen's University.

THE great variety of treatment which, has, from time to time, been recommended for pneumonza, and the great success attri- buted to each variety, would alone be sufficient to raise a doubt in our minds as to the identity of the affection, particu- larly when we find these opposite modes of treatment recom- mended, not fbr different stages of the same disease, but in order to resist its progress from the commencement.

This great variety of treatment is not merely warranted~ but practically found of the greatest advantage; not because the type of the ailment varies according to the previous con- stitution of the patient, but because the generic word pneu- monia comprises several distinct forms of disease. What is the precise seat of the inflammation in pneumonia? is the question invariably discussed by all writers on intra-thoracic disease; and each constituent part of the lung separately, and all collectively, have at different times been declared as the seat of the inflammatory effusion. Thus, it is stated that "pneumonia consists of an exudation into the vessels and tissues o[ the lung ;" that " the solidity of pneumonia arises not from any deposition of lymph into the air-cells and tubes, but merely from an excessive congestion of blood in the vessels." Again, " t he seat of the effusion of plastic matter in pneumo- nia is in the fine air-passages within the lobules of the lung, the interlobular passages being free ;" and to these might be added various other pathological views, which different authors have taken of this vexata qu~stio, not omitting that lately ad- d u c e d - " Whether the capillaries of the bronchial arteries, or those of the pulmonary arteries, are the seat of inflammation."

The celebrity and high character of the various authors who have made and published these investigations were, alone, sufficient proof that great and, doubtless, important differences are found in the morbid anatomy of pneumonir inflammation ; but our own daily experience confirms it. It is not meant that a form of pneumonia is now observed, which differs in its anatomical characters from one observed long ago ; or, as some authors say, that the type of disease has altered, and that, in- stead of acute inttammatory pneumonia, we now have, in gene- ral, to treat a secondary or typhoid affection. The anatomi- cal differences--and they are various--which Bouillaud began

96 Da. GOrCDON on Pneumo~ia.

to describe, are only now being fully ascertained, and it is for us to discover if there-exists any essential differences in the disease, according to its anatomical situation; if there are any symptoms or physical signs by which these differences can be established during life, while yet there is any practical use in the discovery; and lastly, whether, these differences being established, we can point out which of the remedies already in use in this disease are suitable for each particular form of it, or can make any addition to those already" provided.

Having been, for several years, an attentive observer of the numerous cases of pneumonia which have, from time to time, been admitted into the Whitworth and Hardwicke Hos- pitals, I have been gradually led to the conclusion, that there are recognisable three essential forms of primary pneumonia, according as the seat of the effusion or other bio-chemical alteration exists originally in the air-vesicles, the cellular tissue, or the pulmonary vascular system. These three forms are found existing in different stages, and there are several subdi- visions of them, according to the nature of the effusion--the primary seat of the effusion constituting the generic distinc- tion.

I t is not, of course, pretended, that we are as yet able, on the post-mortem examination of' any given case of far advanced pneumonic inflammation, to specify with any degree of cer- tainty the exact and essential seat in which the disease origi- nated; nor, fortunately, is it a matter of much importance to be able to do so ; but I differ greatly from those who consider it neither an important nor difficult matter to establish in what immediate tissue of the lung the disease originates. Its im- portance is only equalled by the difficulty; and, impre~ed with this conviction,, I have for some time endeavoured to classify the different cases of pneumonia which I have met with, according to the original seat of the disease, and to de- termine, accordingly, the mode of treatment to be adopted.

The statement of Hodgkin has, I believe, never been ques- tioned, t ha t " gray hepatization, or gray softening of the lung, includes two totally different conditions ;" but instead of the diathesis of the patient, or the state of his health at the time, being the immediate cause of the nature of the effusion, this latter is immediately determined rather by the tissue originally implicated, while the constitutional powers and habit of the patient will determine the degree of inflammation, the rapidity or slowness with which the progressive alterations in the effu- sion will take place, and other important points which may, perhaps, hereafter be considered. I shall not, at least on the

DR. GORDON 0~ Pneumo~ia. 97

bPresent occasion, allude to the distinctive characters which elong to each of the different forms of pneumonia, or, what

is even more important, to their respective treatment, but con- fine myself to that which has its pmmary seat in the interior of the pulmonary vessels, and would wish the following re- marks to be considered as referring only to this particular form of pneumonia.

Pneumonia, originating in the pulmonary capillaries, ap- pears to be essentially a blood-disease, and sometimes, comes on very suddenly, at other times more slowly ; hke all diseases of this type, it is often epidemic ; it sometimes supervenes on other diseases, but often attacks persons who were previously in apparently good health. The great chemical alteration which the blood would appear to undergo, consists in the augmenta- tion of the fibrine, but this augmentation taking place, amongst other modes, by the conversion into it of a more or less consi- derable quantity of the albumen: we thus have two distinct morbid actions taking place within the sanguiniferous system, one consisting in the removal of the great nutrient or formative power in the blood, and the other in the sudden engorgement of the capillaries with a great mass of (most probably) crude fibrine, which, partly from depressed vital action, and partly from mechanical over-dlstention, they are unable to transmit.

�9 The. symptoms and physical signs with which this form of disease is attended are such as are not merely easily reconci- lable with this impoverished condition of the blood, and en- gorgement of the pulmonary vessels, but such as we might naturally expect to be produced by such amount of morbid action... I t rarely happens.that we have an. opportunity of ex- amining the lungs of a patmnt who has dmd in the very early stage of this affection�9 I have said above that the disease is frequently epidemic; it would seem to have been so in the ~ a r 1841, at which time I was Resident Clinical Clerk in the

ardwicke Hospital; it then attacked se~,~,~eral patients who were recovering from fever, and their strength being already greatly reduced, some died within a few hours from the com- mencement of the attack; these cases were carefully noted by me at the time, and the post-mortem appearances were exhi- bited at different meetings of the Pathological Society ~ by Dr. Corrigan, Physician to the Hospital. Cases apparently similar were also noticed about the same time by Dr. Stokes and Dr. O'Ferrall. One of Dr. Corrigan's communications on the sub- ject terminates as follows : - -" The circumstances I have men-

�9 See Reports of Pathological Society of Dublin, vol. i. pp. 53 and 71. VOL. XXI I . NO. 4 3 , N . S . H

98 Da. GoaDo~ on P~eurnonia.

tioned, if confirmed by future observations, would go to esta- blish an idiopathic form of disease, characterized chiefly by an atonie state of the vessels, and in which the symptoms were not amenable to an~ of the usual modes of treatme~t."

The appearance of a lung when seen in the very early stage of this form of pneumonia is very unlike that produced by acute inflammation of the air-vesicles of the lung. When first seen after the opening of the thorax, it presents a dark-blue colour. This appearance, however, is very evanescent, and is almost completely lost in the course of three or four hours after the lung has been removed. When grasped in the hand, it feels like muscle ; bfit, unlike what is usually termed carnified lung, it is increased rather than diminished in size, but is not so much increased as in the more ordinary form of pneumonia: it is firm and heavy, and sinks in water, but does not appear to have any tendency to pass into any form of hepatlzation, nor does it afford any feeling of crepitation, or anything allied thereto. This description, which I have borrowed from my reports of the cases above alluded to, and from Dr. Corrigan's demonstration of the appearances before the Pathological So- ciety, as well as from subsequent examination of other similar cases, appears to me to indicate a modification of pulmonary disease altogether different from ordinary vesicular pneumoma, nor et to be confbunded with pulmonary apoplexy, or " t h e

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collapse of the lung as connected with bronchial obstruction," described by Gairdner and others.

The symptoms which existed in those who died .. . in this very early stage were great and sudden collapse, sudden hvldlty, and coldness of the surface; the lips became purple, and a dark flush arose on the face ; they complained of excessive weakness ; there was great depression of s t rength--m fact, in no case could the asthenic character be better marked." In some cases the patient complained of difficulty of breathing; but even when there was no complaint uttered, the increased rapidity of the respiratory acts--in one case they amounted to sixty in the mlnute--lndicated great pulmonary obstruction. The respira- tion was usually diaphragmatic ; the tongue was moist and dark- coloured ; the pulse small, feeble, and very rapid ; the surface of the body almost cold; there was seldom any complaint of cough, but there was frequently paln in the side, which was not always referred to the part where the physical signs showed the existence of disease. These physical signs were, great dulness on percussion over a certain portion of the chest, according to the extent of lung engaged, which did not seem to follow any precise rule; in some instanccs the upper part of the hmg was

l)m GoRI)O~ on Pneumonia. 9.9

Lffected, sometimes the lower, sometimes portions of both tings : and, corresponding to the amount of' dulness, there was ither absence or great feebleness of the respiratory murmur.

Patients-who died in this stage of the disease died generally ,f collapse. I have never seen those extreme symptoms to ttend this disease, except in individuals who were greatly educed by previous illness or some other cause: they gene- ally, but not always, prove fatal. Several recovered during he epidemic in 1841, and.within, the last two months I saw a ery well marked case of it, whmh,recovered under Dr. Cor- igan's care, in the Hard.wicke Hospital.

The symptoms which attend the disease, as it generally omes under our notice, and which seem to distinguish it from rdlnary pneumonia, are, t ha t - - l .The peculiar heat of the skin, ) forcibly dwelt upon by Addison, as almost pathognomonic fpneumoma, does not exist ; the skin is never very hot, some- mes dry, often cool, and even perspiring; but it very early :quires a peculiar jaundtre as eet, which it retains throughout,

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ad often does not lose for some tlme after all physical evidence f disease has vanished. This symptom was very strongly larked in several cases lately in hospital, some of whom am ;ill under observation. 2. The cough is altogether different l character from that of ordinary pneumonia: it is very short, equent, and perforn~ed without any apparent muscular effort hatsoever--very unlike the painful and distressing cough so "ten witnessed in vesicular pneumonia. 3. There is seldom ly expectoration ; when it does occur, it is not viscid, nor ho- ogeneous, nor tenacious. 4. There is seldom much pain in the :le ; never the acute, stabbing pain which occurs in vesicular leumonia from the pleura being implicated, because we rarely ld pleuris existing in this form of disease, and, as we re-

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arked before, we often find the patient refer the pare which �9 does complain of to a part of the chest where we have no her evidence of disease existing. 5. The high fever which tends vesicular pneumonia is absent; the pulse is seldom re- arkably frequent; it is always feeble, and soon acquires a ~euliar jerking feel, which i~ owes to the tenuity of the blood. he patient has frequently a listless and careless manner, and ~pears unwilling to speak even about his illness. Such was e case in a boy, about nine years of age, who was admitted to the Hardwieke Hospital, on June 5th, with solidifica- ~n of almost the entire of one lung; yet neither he, nor his rents, who came with him, mentioned any one symptom from rich such disease might be in~erred. ~ The prominent symp- ~a for which they requested relief wa~ constant vomiting. In

~ 2

100 I)R. GORDON on PneumoT~ia.

some cases the pulmonary affection is accompanied by aft attack of herpes labialis. There is always complete loss of ap- petite Ibr solid food, but often great thirst ; considerable modi- fication of the voice often exists, amounting in some instances very nearly to aphonia ; there is sometimes restlessness, and oiten insomnia. The physical signs arc very constant: there is a dull sound on percussion over the affected portion of the lung or lungs, and at first very feeble respiratory murmur, which, however, maintains somewhat its vesicular character, but soon becomes very decidedly bronchial. The peculiar crepitus of vesicular pneumonia is never audible. I f the patient recovers, the progress of the physical signs is very remarkable; some- times within twenty-four hours the extreme bronchial respira- tion and bronehophony are rep.laced by a feeble or even ordinary vesicular murmur, proving that the air-cells merely suffered obliteration from pressure, which, being removed, they again expanded.

The patient seldom dies in this stage: when he does, it is generally fbund that a very great portion of the lungs is en- gaged in the disease; they are very tough and heavy, and a section of them exhibits an uniform light gray colour. -But the progress of this affection is very rapid (it seldom extends over a period of weeks, like some cases of vesicular pneumonia, which have passed through all its stages), and the lung seems readily to pass into a condition somewhat allied to gangrenous degeneration. Effusion now takes place into the bronchial tubes, and the patient dies asphyxiated. Post-mortem exami- nation usually shows the lung to be of a dirty gray colour; there is no welt-marked suppuration, but a species of general softening, and commencing decomposition.

In the last volume of this Journal my colleague, Dr. M'Dowel, has drawn attention to the "connexion between certain forms of pneumonia and renal disease," and under cer- tain circumstances he considers the pneumonia to be one of the secondary affections of Bright's disease. While I have no reason to question the accuracy or validity of Dr. M'Dowel's conclusions, I think that the converse of this proposition is also found, and that a modification of renal disease, sometimes at least, accompanies or succeeds this form of pneumonia ; my reasons for making this assertion are, that on several occasions, while testing the urine to discover if the chlorides had disap- peared from it, I found that in general they had not, but that the urine contained albumen ; knowing that this fact had been already alluded to as of occasional occurrence in pneumonia, I at first did not pay much attention to it ; but more extended ob-

DR. GORDON on Pneumonia . 101

servations proved that the relation between the existence of albumen in the urine and this form of pneumonia was alto- gether different from what we might a pr lor i have expected. Among the last cases of this disease, wMch came under my notice, were those of No. 1, $ohn Kealy, aged 44, admitted into the Whitworth Hospital, June 11; No. 2, James Mullen, aged 18, admitted into the Hardwlcke Hospital, June 28 ; and No. 3, Miohael Leonard, aged 9, admitted into the Hardwicke Hospital, June 5.

In none of these patients was there any reason to suspect the previous existence of any renal disease, and the examina- tion of the urine gave the following results:--No. 1, had been for some time suffering from rheumatism, when he was attacked with pneumonia in the inferior portion of the left lung ; when admitted, there was no evidence of albumen in the urine; its sp. gr. was 1"026. He was for some days under treatment before there was any physical sign of improvement in the lung, or any sensible alteration in the urine. On the 17th the bronchial breathing became less loud, and albumen ap- peared in the urine, which gradually continued to increase tbr some day.s; it then agaln . . . . decreased in quantlty. Although there remained no physical sign of disease m the lung, yet this patient did not regain his strength nor lose his cachectic appearance, and the albumen continued to appear in the urine. In this condition he left hospital on the 4th of July. No. 2 was admitted with solidification of almost the entire of the right hmg ; the disease appeared to have begun at the apex ; there was no albumen in the urine : on the third day the lung began to clear, and albumen appeared in the urin% and con- tinued fbr some days; it had completely disappeared long before he was declared convalescent. No. 3 was admitted with pneumonic solidification of the lower half of the right lung; there was no albumen in the urine; in forty-eight hours vesi- cular respiration had in. part replaced, the bronchlal, breathlng, and albumen appeared in the urine ; on the following day the patient had suffered a relapse ; the bronchial breathing had re- turned, and the urine was no longer albuminous; the patient after this recovered, although very slowly, but the albumen never reappeared in the urine.

In other cases there was no evidence of albumen in the urine throughout the entire illness. I have had no opportu- nit.y,, since the publication of Dr. M'Dowel's essay, of ex- amining the urine in the last stages of this form of pneumonia.

I would hence infer that the amount of albumen which may appear in the urine of a patient affected with this form of

102 DR. GORDON On Pneumonia.

pneumonia, is not indicative of the amount of pulmonary dis- ease, nor does its accumulation prove the extension of the pneumonia; but that, on the contrary, from the appearance of albumen in the urine in such cases, we may anticipate an amendment in the original disease; and that, from a sudden disappearance of albumen from the urine we may dread a re- lapse of the pulmonary affection.

When. . such symptoms exist during life,, we are not to be surprised if, when these cases prove fatal, diseased appearances are found in. the kidneys.; there is, perhaps, no organ in which we. are so httle able, with any degree of accurac, y, to deter-. mine from the appearances the duration of the d~sease. Thin circumstance., and the knowledge that we can, by simple in- jection of the organ, so closely simulate some of the forms of .Bright's disease, render it probable that the renal affection is, m many instances, contemporaneous with, if not subsequent to, or consequent on the pneumonia. I f this view be correct, it would be probable that the same blood disease which affected the lung would in some instances simultaneously affect the kidney also, but that the evidences of this latter affection would not be so early manifested. Examples of" this form are not rare ; the previous absence of drops.y, and of all the usual symptoms of renal disease, warrant us m supposin~ that such could not have existed before the pulmonary affection, while the post-mortem appearances place beyond doubt their contamination for some time before death ; nor is this appear- ance of blood-contamination confined in those cases to the kidneys; the same thing is often observable in the liver and

�9 " n spleen in the "oleo-albumznous deposits which we fi d therein. But in other instances it would appear that the lung recovered itself by means of the albuminoid matter passing off by the kidneys, as in the cases above quoted. I t is probable that this attempt is made in all such cases, but that, in some in- stances, having failed, it is succeeded by certain organic changes in the kidney. These sources of failure may arise from the great amount of blood-contamination which originally took place, i. e. from the great virulence of the disease ; 2ndly, from the extent or number of the organs attacked; 3rdly, t~om the patient being in a previously enfeebled condition ; and, lastly, from neglect or unsuitable treatment.

Perhaps one of the best marked features of this disease is, " i t s not being amenable to any of the usual modes of treat- ment." I need not here allude to the more than inefficacy of abstraction of blood in any form to meet its requirements. The treatment by tartar emetic is equally inapplicable; and

DR. GORI)0~ on Pneumonia. 103

the mercurial plan of treatment, as it is termed, is also power- less to control this formidable affection. The treatment by the internal use of oil of turpentine, so advantageous in the suppurative stage of vesicular pneumonia, does not appear to have any influence on this form of disease. Wine and the usual diffusible stimulants support the patient's strength and add to his vital energy, and so are of use, but they seem to have no specific power over the disease, such as is evidently exercised by the sulphate of quina. During the last eight months I have treated with quina all the cases of this form of pneumonia which I have witnessed, and I have had the opportunity of observing several cases similarly treated by Dr. Corrigan in the Hardwicke Hospital. On the 19th of April last Dr. Corrigan presented to the Pathological Society a spe- cimen of this form of pulmonary disease, when he took occa- sion to allude to the efficacy of quina in its treatment. The result of this treatment has been that, of the cases which came under observation before effusion had taken place into the bronchial tubes, none proved ii~tal ; while some few recovered, even after the lips had become blue, the face congested, and mucous rhles were audible in the bronchial tubes.

The beneficial effects of quina in the /~dvanced stages of p.neumonia, when the patient is old, and the constitution debi- litated, have long since been recognised ; and we occasionally find authors alluding to the use of this drug as indicated by, or as a remedy for, some one particular symptom; thus Dr. Todd says : - - " In the decidedly typhoid cases~ I need scarcely say that the free use of stimulants is of essential service, and it is ohen of immense advantage to give" quma" freely; the .spe-,, cial indication for this latter drug being profuseness of sweating. And Dr. Morehead, in his recent work on the Diseases of Indl"a, recommends the use of quina in pneumonia " characterized by its coexistence with fever of remittent type ;" and Professor Wood recommends " the addition of sulphate of quina when hectic symptoms appear." But . . . . . the advantages to be derived from the early use of this medmme m this pamcular form of pneumonia have not been sufficiently dwelt upon. The average dose administered was five grains every three hours (in a few very severe cases ten grains were given for the first dose); in some instances it was deemed advisable to continue its use in this quantity for several days ; yet in no instance did I observe any untoward result to arise. The first indication of recovery was, in general, a marked alteration in the character of the pulsc, which also decreased in number; while, as to physical signs, the rapidity with which the bronchial breathing and extreme

104 ~)R. ~ O R D O N On P n e u m o n i a .

dulness disappeared from an entire lung, or portions of both, was truly surprising. It was not found necessary, or deemed advisable, in any. instance to. precede, its .administrati~ by the use of a purgative or emetic, as adwsed in other instances. In the case of Leonard, nine years of age, who was admitted with vomiting, I at first hesitated, but th-e symptoms of the disease were so well marked, and the entire of one lung was so deeply engaged, that I ordered it to be given in two-grain doses every three hours ; after the third dose the vomiting ceased, and did not recur; and on the fourth day the boy was convalescent.

And, if the pathology of this disease be such as I have en- deavoured to describe, the treatment by quina is that from which, of all others, we would naturally expect the greatest advantage. The action of quina " is exertedprimarily in the blood (Headland), and not on the nerves :" Tiedemann and Gmelin found it long ago in the blood of a patient to whom it was administered ; and Cochran, in a late Number of the Char- leston Medical Journal, pointa'out in what its action consists by detailing its effects on the uterus. He says : - - " In women under its influence, if they were menstruating, they com- plained of increase. In some cases it hastened the flow if given just before the period ; it provoked their return when suddenly suppressed by cold, &c. An important circumstance connected with the action of qulna, and which may throw some light on its mode of action is, that, i f administered in large doses, and frequently repeated, it defibrinates the blood, rendering it fluid and ineo.agulable; this fact has been clearly established by the experience of Baldwin, Melier, Briquet, and other respectable authorities TM.

�9 Since these observations were in type, Dr. Corrigan has published, in " The Dublin Hospital Gazette," some cases of asthenic vesicular pneumonia, which he treated with quinine Dr. Corrigan considers that its mode of action is by stimu- latinff the capillaries of the lung, and that its action on the spleen is also similar.