| Taking the ordinary case of rather virulent pneumonia in which there are indications for Baptisia, there is usually a history of a fairly slow onset of the disease. Occasionally in the course of a very virulent epidemic you will find Baptisia cases developing with astonishing rapidity, even in a few hours, but in the majority of cases, in an average winter, the onset is much slower.|
The first outstanding characteristic of Baptisia pneumonias is the befogged mental confusion. The patients are dull mentally, they find it difficult to think, they find it difficult to answer your questions, and you will probably have difficulty in taking the case as very often they do not remember the details of their illness. Their speech is rather slow, and often you will find them becoming mildly delirious quite early in the course of the disease. It is a gentle, wandering delirium, with again a good deal of confusion as to where they are and what they feel like. Very often you will find them drowsy; you can wake them up, but if you do you will get an incomplete answer and then they will drowse off again.
Another Baptisia symptom is that in spite of their drowsy state these patients are restless. They have generalized aching pain, they complain of their bed being hard, it hurts them to lie and you will find them moving about to get a more comfortable position. Sometimes that restlessness is associated with their inability to locate what is happening to them, they feel their arms or legs are uncomfortable and they move about to make sure where they are, or what is happening to them.
Another point is that these Baptisia patients are always cyanosed. They have rather a puffy, cyanotic appearance, their eyes look heavy, usually half closed, their lips are cyanosed, and there is a lot of sordes about the mouth. The mouth itself is always offensive, and very, very dry indeed. The tongue usually has a brown coat down the centre; it may be yellow to begin with, but it usually very rapidly becomes brown. The tongue itself is very dry to touch. But, in spite of this intense dryness of the tongue, you do not get excessive thirst in the Baptisias. They will take a sip of water, but that is all they want; for one thing they cannot be bothered, and for another the thirst is not excessive.
The skin surface of the Baptisia patient is always hot and damp, and the patients often complain of very unpleasant waves of heat all over. Always with their damp sweat they develop a very heavy, unpleasant odour.
The main complain is a feeling of intense oppression in the chest, and with this sensation they are rather afraid to lie down because lying seems to increase it and makes them feel as if they are going to suffocate. Very often they will tell you that the feeling of compression is not so much a sensation of the chest wall being tight as of the lungs inside being compressed, and this at once distinguishes it from the ordinary tightness of the chest which you find in so many of the other drugs.
Another characteristic about these patients is that they have a rather scanty sputum, which is very sticky and difficult to expel in spite of the fact that there is often a good deal of rale in the chest.
In appearance the patient is not unlike a very much more toxic Bryonia patient.
| The Pyrogen pneumonias are usually much more rapid in their onset than the Baptisias. Mentally the patients are quite different. You will always get a certain amount of loquacity in your Pyrogen patients. They are rather impatient, they talk fast, they talk a good deal, and they are liable to be rather irritable.|
In appearance the Pyrogen patients tend to have a brighter flush, they are not quite so cyanotic as the Baptisia. On any exertion, coughing, or anything of that sort, they tend to flush up much more, and they then become definitely dusky. After a paroxysm of coughing the colour tends to ebb, and they may become definitely pale.
The temperature tends to be definitely higher than in the average Baptisia case, running up to 104 degree or 105 degree, and it is always accompanied by very considerable hot sweat.
The tongue in Pyrogen and Baptisia cases is sometimes very difficult to distinguish as you will get Pyrogen patients with one that is almost as dry as it is in Baptisia, and with the same kind of brown, dry coating. But occasionally you will come across a Pyrogen patient with a much redder tongue with less coating on it, and which is very dry and accompanied by a good deal of thirst.
Both these patients suffer from waves of heat, but in Pyrogen they are always followed by waves of shivering-they are alternate hot and cold waves. It is almost as if the patient suddenly blushed from his toes to his head, exactly the same thing as would be described as “hot flushes”.
In both the Baptisias and the Pyrogens there is exactly the same complaint of general soreness, which is described in the same way; they say the bed is too hard and they move about to try to get an easy position, which makes them restless. They give exactly the same description of not knowing where their arms and legs are, and they both say they are moving about in order to bring their sensation back to normal. You cannot distinguish the one from the other in this respect.
There is one point you can tack on these aching pains, and that is that in Pyrogen cases you quite commonly hear the statement that the illness started as an aching in the legs which gradually spread up. It is a quite frequent story.
In contrast to the chest symptoms in Baptisia, the Pyrogen case suffers much more from a sense of general oppression of the chest, with a good deal of aching soreness actually on the chest wall. And the respirations in the Pyrogen case are always very rapid and very shallow, which is frequently the case in Baptisia also.
The sputum in the Pyrogen case tends to be more profuse, it is somewhat pussy, and it is always offensive.
Then there is one other point which at once distinguishes the Pyrogen pneumonia from that of any other drug in the Materia Medica, and that is that there is always a discrepancy between the pulse and the temperature. That discrepancy may be a very rapid pulse with a comparatively low temperature; or equally commonly it may be a high temperature and a comparatively slow pulse. It may go either way, but it is the discrepancy between the pulse and the temperature that really matters.
| Lachesis is very similar to Baptisia and Pyrogen. I think in the majority of cases you will find your Lachesis pneumonias cropping up later in the winter or in the early spring. You very often find them cropping up just at the end of a cold spell when the weather is beginning to get warmer. In these pneumonias you have to acquire an entirely fresh picture of Lachesis from the one you associate with Lachesis in the chronic patient. For instance, you know your chronic Lachesis patient simply talks your head off, but in the pneumonias where Lachesis is indicated you are much more likely to get the extremely toxic, fuddled, maudlin, drunken sort of patient. They are rather heavy looking with a mottled, cyanotic appearance, a very puffy-looking face, and puffy, swollen-looking, cyanotic lips. Their speech is thick, they have difficulty in articulating, and they are liable to drop half their words. They stumble over what they are saying, and frequently they leave a sentences half finished.|
Another point that is sometimes helpful in spotting your Lachesis patient is that their very cyanotic, swollen-looking lips tend to become incredibly sensitive to touch.
Quite frequently these people go on to a frank delirium tremens, with all sorts of delusions. They hear voices, they imagine all sorts of things, they become suspicious, they think they are being poisoned, and they refuse to take their medicine. As far as the appearance of the tongue is concerned, it is always a very dry, swollen, dark red tongue. And in spite of that dry tongue you will get a good deal of very sticky, stringy saliva in the mouth. These Lachesis patients have great difficulty in breathing, and they are simply terrified to lie down. They hate to go to sleep because of this sense of suffocation, and if they do drowse off they are almost certain to wake up with a sense of suffocation and a most distressing attack of coughing.
There are one or two definite Lachesis symptoms which are useful. These patients mostly get a very violent, surging head- ache with their cough. It feels as if all the blood in their body is forced into their head. Their head is hot and bursting and yet at the same time they often complain that their legs, feet, and very often their hands, too, are feeling icy cold.
Then with their chest involvement they always have a horrible feeling of fullness in the chest, which may be just behind the sternum, or it may be in either side. More commonly the main involvement is on the left side in Lachesis pneumonias.
There are two very typical Lachesis symptoms. One is that with their respiratory distress these patients always have a horrible choking sensation, a feeling of tightness round their throat, and they cannot bear to have the blankets up round their neck as they feel they would strangle if they did. The other is that although they get acute stabbing pains in the chest, very often on the left side of the chest, they cannot bear any pressure on the chest at all. This distinguishes Lachesis from so many of the other drugs with stabbing pains which are relieved by firm pressure on the chest.
As regards the sputum, in Lachesis it is usually scanty. The patient feels as if he had a lump in the chest and as if he could shift it a certain distance but when it got half way it stuck. You can hear the rattle in the chest, and yet the patient cannot expel anything.
Occasionally you come across an apparent contradiction in that sort of muddled, besotted patient. These Lachesis patients sometimes develop a hyperaesthesia over the affected area of the chest, which is exceedingly sensitive to touch. They may develop a hyperaesthesia to noise. They may become very sensitive to light. And they are often hyperaesthetic to smell: for instance, you notice that during the period when smoking is allowed in the wards the Lachesis patient is enormously distressed, quite out of all proportion to the actual odour.
| I think you are liable to meet with Mercury pneumonias about the same time of the year as Lachesis ones, that is in the later part of the winter. In their pneumonias at first sight it is awfully difficult to distinguish your Mercury mentality from the Lachesis mentality, but in appearance I think there is a certain amount of difference.|
Like the Lachesis patient, the Mercury patient tends to have a very puffy face, but it is rather more livid in colour and gives you the impression of being more sickly looking, the patient looks more ill somehow. I think the Mercury patient is a little more sweaty, and the skin looks a little more greasy.
As regards mentality, you get very much the same sort of D.T.’s developing in the Mercury patients as in the Lachesis, and they become just about as suspicious. Their speech is almost as difficult, it is rather hurried, and they tend to fall over their words; but it is much more a case of stammering than of failing to finish a sentence in the way Lachesis patients do. I think the Mercury patients are rather more irritable, and they are definitely more anxious and more restless.
The next thing which helps you is that in the Mercury patients there is very marked, generalized tremor-tremor of the hands, tremor of the tongue, tremor of the facial muscles.
Then in Mercury there is much more commonly a tendency to ulceration of the corners of the mouth, and a much more profuse, watery salivation; it is not so stringy as in Lachesis. Quite often you will find definite aphthous patches in the mouth, on the insides of the cheek, or on the tongue, and these usually sting and burn on touch.
The appearance of the two tongues is dissimilar. In Mercury it is a rather swollen, flabby, pale, greasy looking tongue. But if the patient has developed definite D.T.’s you will find it becoming more coated and tending to be rather drier. The patients usually complain of an unpleasant, sweetish, offensive taste.
In these Mercury patients there is always a pretty profuse, generalized sweat. As a rule is a swinging temperature, and you can link on to that the general Mercury instability to heat, they are either far too hot or far too cold. The Lachesis patients, of course, are always hot, they cannot stand heat. And incidentally your Lachesis patients are thirsty, they want cold drinks, and they very often get a horrible choking sensation if they attempt to take anything hot; it very much aggravates their distress and aggravates their embarrassment in breathing. The Mercury patients tend to be much more thirsty than the Lachesis ones, and they have an incessant desire for ice-cold drinks.
The cough in Mercury tends to be rather different. It is usually a dry, racking cough. And here you will very frequently get a typical Mercury indication, which is that the cough tends to come in double paroxysms. The patient has a violent paroxysm, then a pause, then another paroxysm, and then a period of peace. Another distinction is that as a rule you get your main involvement on the right side in Mercury, rather than on the left side as in Lachesis. Very often it is right lower lobe which is affected, and there are sharp stabbing pains going right through to the back.
As far as the sensation in the chest is concerned, it is not unlike the Lachesis feeling that the chest is full, and with their paroxysms of coughing the patients often tell you they feel as if their chest would simply burst.
Finally, the sputum in Mercury is, I think, rather more profuse than in Lachesis; it is rather more liquid, it is usually pretty dark in colour, and it is always offensive.
In discussing these complicated pneumonias you will notice I have taken all the rather hot, congested, muttering types together. There are two other drugs which I ought to mention for the same conditions, and the distinguishing point about them is that they are both definitely chilly, in other words, the patients are sensitive to cold, which immediately differentiates them from the four drugs we have already taken. These two are Hepar sulph. and Rhus tox.
| Where you are dealing with, a Hepar pneumonia you always have a septic type to extend with, and you get the impression that the patient is very ill. As a rule Hepar patients is very ill. As a rule Hepar patients are palish in appearance, although they may have a somewhat hectic flush. The skin surface is usually moist, with a rather sour-smelling sweat.|
The first thing that will strike you about these patients is their extreme sensitiveness to cold. Your Hepar patients are very chilly, they want their blankets right up to their necks, they want their room as hot as they can have it, they hate to have any draught in the neighbourhood at all.
Mentally, they are very difficult . They have a horrible, discontented, dissatisfied, critical outlook. They have a marvellous faculty of remembering any unpleasant occurrence that they have had. They will probably tell you they have seen another doctor the day before and he did not do them any good; or else they will tell you that the nurse did not carry out your instructions. They always have a complaint of some kind.
These Hepar patients are definitely over-sensitive. They are disturbed by their surroundings, they are disturbed by any noise in their neighbourhood, and they very often react unpleasantly to particular people, for instance you will find they take a dislike to one particular nurse in the ward, and nothing she can do is any good.
Their speech is always hasty, the words simply tumble out of them in a gush, and it is usually a complaint of some kind that they have a talk about.
They tend to develop a definite labial herpetic eruption, or a crack at the corner of the mouth. The upper lip tends to be rather swollen, thickened, and very reddened. Quite often in these Hepar pneumonias there is a deep spilt in the centre of the lower lip.
The tongue is always very sensitive. Very often they complain of a hot, burning tongue or of a burning tip to the tongues, and you often find aphthous patches scattered about the mouth, either on the sides of the tongue, or on the lips, and they are always horribly sensitive. These patients usually complain of a rather bitter taste.
One point which always strikes me as a contradiction in the Hepar patients, is that, in spite of their very sensitive mouth, they like rather highly tasting drinks and food, something with a bit of a bite about it.
These patients have two main physical complaints. One is a sense of extreme weakness in the chest. The other-and this is much more common- is acute stabbing pains in the chest. These pains are accompanied by a definite aggravation from lying on the affected side. You will find as we go along that the position taken up by the patient in pneumonia is constantly cropping up as a differentiating point; one could almost spilt the drugs into two groups, those in which the patient is ameliorated by lying on the affected side and those in which the patient is aggravated by
As regards the cough, in Hepar it is always a very choking, strangling, spasmodic cough. It comes in quite frequent paroxysms, and is accompanied by acute dyspnoea. In these paroxysms you will find the patient sitting up in bed with the head tilted well back, and in their pneumonias the cough is accompanied by a very profuse, usually purulent, blood-stained sputum. A striking thing about the cough is that it is appallingly easily produced by any cold, for instance, you merely have to wave anything in the neighbourhood of a typical Hepar patient to produce one these spasms, and if the patient even puts a hand out of the blankets a paroxysm will be started if the hand gets chilled.
As a rule the temperature in these Hepar cases is a rather swinging septic type of temperature. It is accompanied by very profuse sweating, and yet in spite of the sweating there is not a definite drop in temperature and the patient feels if anything more uncomfortable for it. Any slight effort on the patient’s part will produce one of these violent sweats.
These Hepar cases always feel very much worse after they have been asleep. You expect your pneumonias to wake up feeling better if they have a decent sleep, but the Hepars always feel much worse. Their sleep is unrestful and they have very distressing dreams, very often they are dreams of fire.
There are two periods at which you get marked aggravation in Hepar. One is round about 6 or 7 o’clock in the evening, When the patients very often have a rise of temperature. The other is about 2 o’clock in the morning. At this time the patients very often have an acute paroxysm of coughing. They are liable to become very exhausted by this and may settle down afterwards and fall asleep, and if so you will get your post- sleep aggravation later in the morning.
| The other chilly drug for this mixed type of infection is Rhus tox. I think in the majority of cases the Rhus tox. pneumonias develop somewhat slowly, and you will very often get a history that the onset of the pneumonias was caused by the patient’s being out and getting soaked-damp in particular is the exciting cause of Rhus pneumonias, and especially cold damp.|
In appearance these Rhus patients are always somewhat cyanotic, they are rather dusky in colour, and they have a moist skin, very often they have a profuse sweat. The lips are very cyanotic, and extensive herpetic eruptions are developed quite early in the disease. I think in Rhus the herpes tends to appear first of all on the lower lip, but mostly by the time you see the patients they have pretty generalized, extensive herpetic eruptions about the mouth.
In their pneumonic attacks these Rhus patients are horribly distressed, they feel ill, they are anxious, and they are dreadfully restless, they cannot get peace at all. They are very depressed, and have a general feeling of discouragement. They will very often tell you that they feel so horribly uncomfortable that they think they would be better if you could only let them out of bed, they say that if they could only move about a little more it would help them.
In their anxiety, particularly if they are becoming a bit muddled, they are very quite liable to get an obsession that they may be poisoned. Quite frequently in these cases you will find the patients becoming mildly delirious. It is a low, restless, muttering delirium, and it is always accompanied by extreme physical restlessness as well.
In addition to general restlessness, in these Rhus cases you will usually get a complaint of pretty generalized aching pains, and the patients say these aching pains are easier if they keep on the move.
The tongue in Rhus is fairly suggestive. In the earlier stages, certainly in the stages before the patients become delirious, you get a typical Rhus tongue, which is a white-coated tongue with a red margin, or a red triangular tip. But by the time the muttering delirious state has developed the tongue will have tended to become brown, and intensely dry. The patients often complain of a horrible metallic sort of taste; they may call it coppery, or something of that sort, but in any case it is very unpleasant, metallic taste. There is always very marked, constant thirst. The patients complain of the mouth and throat feeling appallingly dry, almost as if burnt, and they have incessant thirst, with a preference for cold drinks.
The cough is always a very troublesome one. It is a constant, tormenting cough, and the patients will usually tell you that they have a feeling of intense irritation in the middle of the chest, somewhere behind the sternum.
The respirations are always very shallow, short, hurried, and difficult.
These Rhus patients are just about as sensitive to cold as are the Hepar patients, and the attack of coughing will be brought on by any cold draught, or any exposure to cold. In both cases when examining your patients you have to be very careful not to uncover them too much or you will precipitate one of these violent paroxysms of coughing.
There is always a certain amount of laryngeal involvement in these Rhus cases, and it may be very troublesome indeed. Short of this, there is always at least a degree of hoarseness.
The sputum in the Rhus case is usually fairly profuse, rather liquid, dark in colour, and definitely blood-stained. The temperature tends to be of the swinging type, but it does not have the same degree of swing as you find in Hepar. As a rule there is rather a full pulse, which is fast and not well sustained.
There are two other points which sometimes help you in your Rhus diagnosis. One is that after a paroxysm of coughing, when the patient has apparently got very hot, he immediately gets a horribly chilly sensation, sweats profusely, feels horribly cold, and wants to be covered up. And the other point, which you can link on to that is that, although they are intensely thirsty, if they drink too much cold water they are apt to feel very chilly, and it is very likely to precipitate another paroxysm of coughing.
As a rule in these Rhus cases the times of maximum aggravation occur during the night rather than during the day. The patients become more restless, more worried, and more inclined to get out of bed, during the night.
B.-CREEPING TYPE OF PNEUMONIA, OR DEFINITE BRONCHO- PNEUMONIA IN ADULT.
There is another class of drugs which I always look on as useful in either the creeping type of pneumonia, or in definite broncho-pneumonia in the adult. You know the type of unpleasant case that starts as a frank lobar pneumonia, and probably twenty- four hours later a patch appears somewhere in the un-involved lung, and the next day there is another patch somewhere else, possibly without much clearing up of the old area. That is the type of case in which these drugs are indicated, and I think you can cover it pretty well with four. On particular indications you may require any of the drugs I have already described, but I think you are more likely to need Pulsatilla, Natrum sulph., Senega, or Lobelia for these cases. They all have certain points of similarity, of course, but they all have their own individualizing symptoms. I think possibly Natrum sulph, is more typical of these than any of the others, so I will start with it.
| As a rule in the Natrum sulph. pneumonias, or broncho- pneumonias, you get a history of a fairly gradual onset. You find physical signs in one area, probably quite a small area, and the condition is steadily spreading. The patients are usually definitely cyanotic, and not infrequently in Natrum sulph. there is a sort of yellowish tinge, there may even be a definite jaundice. It is a quite frequently indicated drug in post- operative pneumonias-pneumonia following an acute appendix, pneumonia following a gall bladder operation, etc.|
The outstanding characteristic of the Natrum sulph. patient, apart from the type of pneumonia, is the mentality. Natrum sulph. patients are always extremely depressed. It is not a weepy depression at all, but they feel horribly gloomy and flat, they do not want to be disturbed, they do not want to be interfered with, they are quite liable to turn their back on you, they do not want to be questioned, and they do not want to have to think. They are quite liable to say “For heaven’s sake leave me alone”. Very often they display a certain amount of irritability if they have to talk to you, and they are strangely sensitive to noise and often acutely irritated by it. They are always sensitive to heat, they cannot bear a stuffy room at all, and they always have a hot, sticky skin surface.