Condition [Late Pneumonia]
Condition [Late Pneumonia]
| In the adult you expect to find the symptoms of Antimony tart. cropping up late in a pneumonia, you do not usually get them in the early stages, and by the time the patients have gone on to an Antimony tart. state they are seriously ill. The appearance of these patients is suggestive, they are pale, they have a pinched look, rather a bluish coloration of the skin, and they are covered with a cold sweat. The nose looks rather pointed, pinched in, and very often it has a somewhat sooty colour. Owing to the extensive chest involvement you will find the alae nasi flapping and with the obvious effort to get as much air in as possible all the muscles down the side of the neck are standing out and the patient is struggling for breath. The lips in typical Antimony tart. cases are rather livid, although if the patients are running towards a collapse, as they sometimes do in Antimony tart., the lips may tend to become paler, and in any case they are usually very dry.|
The impression you get of these patients is one of extreme suffering. They are intensely distressed, and their main reaction is one of wanting to be left alone-“For heaven’s sake don’t disturb me.” They do not want to speak, they do not want to speak they do not want to be spoken to, and very often they do not even want to be looked at. The patients themselves are very miserable, and you often find them lying panting for breath and moaning.
As a rule there is a very thick coating to the tongue; it is a horrible, pasty, white coating, and the tongue looks just as if it had been painted with white enamel. in few cases you may find a somewhat brown coat, which is very dry, but that is exceptional. The outstanding point is that, in spite of the dryness of the lips and tongue, these Antimony tart. patients are completely thirstless.
Another practical point to remember is that these Antimony tart. cases have a loathing of food of any kind, and in particular any attempt to feed them on milk will produce an acute nausea-the Antimony tart. patients have an acute intolerance of milk.
As far as the actual chest condition is concerned, there is invariably an excessive secretion of mucus; standing by the bed you can hear the moist bubble in the chest. There is a very rattling cough, and yet, in spite of the rattle, there is very little sputum expelled. With the effort to expel that sputum the Antimony tart. patients usually suffer from pretty acute nausea, and they may actually vomit.
With their violent cough these patients suffer from a great sense of oppression in the chest, and very often there is great soreness of the chest wall. They cannot bear any weight on the chest at all, they want to push the blankets off, they want to get them away from their neck, and any suggestion of weight, even a single blanket, will embarrass them.
These patients are very sensitive to any stuffy atmosphere. They have an acute air hunger, and a warm room makes them very much more uncomfortable. And an important point is that they are particularly aggravated by any radiant heat.
With the extensive chest involvement, the hands and fingers, feet and lower extremities, are very liable to become bluish, cyanotic, also the patients become very tremulous and, in spite of their general heat and aggravation from warmth, they very often complain of a feeling of coldness from about the knees downwards. As you would expect in a case of this kind, it is impossible for the patient to lie down flat; the only thing that gives him any comfort at all is to be propped up in bed, at the same time avoiding any suggestion of constriction of the chest.
I do not think there is any particular preference for either side of the chest in Antimony tart; I have seen as many cases involving the left side as the right.
Another point is that in these Antimony tart. cases there is always a tendency to heart failure, the circulation is giving out, the pulse tends to become irregular, and the heart tends to dilate.
Well, that is the kind of case that we meet here from about the fifth day of disease onwards. We quite frequently see patients coming in in that state. But we do not expect a patient ever to get into that state once he is in the hospital.
In Antimony tart. we have just discussed one type of very serious case. The next one, which is just about as serious, is Carbo veg., and at first sight it is a little difficult to distinguish between it and the Antimony tart. case. However, there are certain distinguishing points.
In appearance, as you first see these patients, there is very little to distinguish the two, the Carbo veg. looks just as ill he has the same sort of pinched appearance, the same respiratory embarrassment, the same kind of flapping nose, and the same bluish colour. I think, in the majority of cases, the Carbo veg. patient is a little more blue, and the Antimony tart. patient a little more livid. As a rule in the Carbo veg. case there is less cyanosis of the extremities, which are more likely to be pale and covered with an icy, cold sweat.
Both these drugs are covered with a cold sweat, I think it is about equally marked in the two. They both have an intense air hunger, but here you find your first distinguishing point. Your Carbo. veg patients say that they have an intense air hunger, and yet they feel frightfully cold, whereas there is none of that feeling of frightful coldness in the Antimony tart. patients.
As a rule, instead of the rather dry, bluish lips of Antimony tart. the lips of Carbo veg. tend to be purplish and somewhat swollen. And instead of the white coating on the tongue which is so typical of Antimony tart. you are very much more liable to get a dirty, yellowish-brown, very dry tongue. Again as a distinguishing point between the two, in Carbo veg. you will get marked thirst, whereas in Antimony tart. the patient is thirstless. The typical Carbo veg. patient wants sips of cold water, and very often complains of a very unpleasant, foul taste in the mouth.
As far as the actual chest condition in Carbo veg. is concerned, you are more liable to get definite extensive areas of consolidation, and rather less generalized bubbling in the chest.
There is usually far more acute rawness in the chest in Carbo veg. than in Antimony tart. And in the Carbo veg. patient you mostly find that the sputum is just about as difficult as it is in Antimony tart.; the patient will tell you it comes up so far and then they just cannot get it out. But instead of that effort to expectorate producing the vomiting that you meet with in Antimony tart., in Carbo veg. it is very much more likely to produce an attack of extreme exhaustion, the patient lying back simply gasping for breath. Incidentally, these Carbo veg. patients respond astonishingly well to the administration of oxygen.
Both Carbo veg. and Antimony tart. have that horrible sense of a load on the chest. It is a feeling of dreadful oppression, which the patients describe either as an absolute weight sitting on the chest, or as the chest being full almost to bursting.
Another distinguishing point is that in Carbo veg. there is always marked abdominal discomfort, a feeling of distension, fullness and flatulence, instead of the intense nausea of Antimony tart.
As far as the position taken up by the two patients is concerned there is very little to distinguish them. They both want to be propped up, and they both want to avoid any constriction of the chest or round the neck, but the Carbo veg. will allow you to put a single blanket up to keep them warm, whereas the Antimony tart. simply cannot tolerate it. Another point about Carbo veg. patients is that they always tend to sleep into an aggravation; they doze off and then wake up simply gasping for breath.
In the Carbo veg. patient, as in the Antimony tart. patient, you have a definitely failing heart.
I think as a rule the temperature tends to be less high in the Carbo veg. case than it does in the Antimony tart. and I think you are most likely to meet your Carbo veg. case just immediately before, or just immediately after, a pneumonic crisis.
As far as relief from your drug is concerned, you should get this almost immediately in an Antimony tart. case, and the Carbo veg. patient should be comfortable in about six hours. It is astonishing how quickly they respond. It is usually a question of acute heart failure, and either the patients respond at once or else you should give one of the other heart failure drugs. I should expect one of these Carbo veg. patients with critical collapse to be out of danger in twelve hours. But they are exactly the type one used to dash at with all sorts of diffusible stimulants. and they mostly died, whereas now one expects them to recover. If you want to cure these cases, however, do not give them stimulants. I have seen cases of that sort in which there was obvious heart failure and the physician had pushed in Coramin and Carbo veg. did no good at all afterwards, it simply did not have any effect. Nowadays I would never employ any stimulant in a case of that sort; I am sure one gets better results without. The only exception I would make would be strong coffee in the case of Carbo veg., as these patients sometimes do respond astonishingly well to it. They have a desire for it, even a craving for it, and it often seems to do them good. But that is the only exception. I would make.
As regards potency, in Carbo veg. one is dealing with an acute collapse, there is a dilating heart and a heart failure, and one must obtain an effect fairly quickly, so my personal preference is to go high and give frequently until I get a definite response. I would give cm’s every ten or fifteen minutes until I got a definite response. The kind of response one gets is that the patient begins to feel warmer. Instead of the icy coldness they begin to feel less cold, they look less cold, they are less cold to touch, and the sweat begins to disappear. I would then space the drug out and give it every half hour, until there were definite signs that the heart was taking up again, in other words, until the pulse was fuller, the distress getting less, and the cyanosis beginning to fade. As a rule you get the patient through the crisis in twelve hours. But to do that you must give frequent repetition to begin with, and you must keep up your action for some hours, giving cm’s all the time. I have tried low potencies in cases of this kind and the patients did not respond at all; I have then jumped up to a cm and the drug has had immediate effect. So much is this so that up in the private wards, where one quite frequently sees these cases, the Sister does not want anything but cm’s for them-that is how experienced Sisters come to look on it, they always want the highest potency you will order as they say the other is a waste of time. That is practical experience, it is not a desire for any particular potency.
Antimony tart. cases are not so acute, in them you are dealing with a water-logged chest rather than a sudden cardiac failure. It is slower in onset, and you have more time to play with. In these cases 10 m’s hourly at first and later two-hourly will be sufficient.
| I think Kali carb. tends to be indicated from about the fifth day of disease onwards, although you may get indications for it earlier. It is a very serious case, but it is a case that you see before the really critical stage comes along. Very often it is a case which has responded to a certain extent to one of your previous drugs, but you are not satisfised with its progress, the patient is still running a temperature and, although more comfortable, is not clearing up. It is in that type of case that you find your Kali carb. indications.|
The appearance is always that of a patient who has been pretty exhausted by their attack. He looks rather pale, flabby, and washed out, and has a sort of haggard, exhausted appearance. Very often in Kali carb. there is a puffy look about the face. The patient always has an anxious, worried, rather frightened expression. And with that there is very often a good deal of tremor of the facial muscles, and twitching of the hands and fingers; he picks at the fingers, and picks at the bedclothes.
These patients dislike being left alone, they get more worried, more scared. They are definitely sensitive, they are very easily annoyed, very easily irritated, and they are particularly sensitive to any noise in their immediate neighbourhood.
The lips tend to be cyanotic, dry and cracked. As regards the tongue, I think most commonly Kali carb, patients complain that it feels as if it had been scalded; it is dry and red and has this burnt feeling. But you will quite frequently meet with a case in which the tongue has a dirty, greyish-white coat. As a rule these Kali carb. patients are not markedly thirsty; their mouth is dry, and they may want a little sip of water, but they are not markedly thirsty.
The cough tends to be very dry, and suffocative in type. And with an attack of coughing you will find these patients breaking out into a profuse sweat. The sputum is always scanty, difficult to expel, and very often it only comes up into back of the throat and is swallowed.
There are two very definite Kali carb. indications. The first is that these Kali carb. patients are frightfully sensitive to any draught of air, it produces a violent attack of coughing, a regular paroxysm, and it also produces a horrible sense of chilliness. The other characteristic point is the position taken up by Kali carb. patients in their respiratory distress. They always want to sit upright, and, unlike the other drugs we have considered, they lean forward and support themselves with their elbows on their knees, or they like a bed table across the bed and they lean forward on that.
Always in these Kali carb. pneumonic cases the patients have violent chest pains with their cough. The kind of pains they get are the stitches right through the chest, or acute stabbing pains in chest. The pains are very much aggravated by any motion, and, of course, they are produced by any of these violent spasmodic coughs. I think as a rule the maximum involvement is on the left side of the chest rather than on the right, and whichever side it is, it tends to involve the lower lobes rather than the upper.
You do not tend to get the same degree of cardiac failure in Kali carb. as you do in the two preceding drugs. You get a weak pulse without a great deal of tone in it, but you do not tend to get the acute dilation of the heart that you do in the others. You get a weak, running pulse, but not acute heart failure.
There is one other useful diagnostic point, and that is the time of maximum aggravation. It is in the early hours of the morning, between 2 and 4 o’clock. You may meet with it at any time during that interval, but you are most likely to get your worst period about 3 o’clock in the morning. Quite frequently you will find your Kali carb. patients sitting up in the typical position, gasping for breath, about 3 o’clock in the morning, with a horrible feeling of oppression and tightness in the chest and acute stabbing pains.
There is one point which sometimes tends to make you confuse your Kali carb.’s with your Carbo veg.’s and that is that in their pneumonias these Kali carb. patients do get a good deal of flatulence, a good deal of abdominal discomfort, and a good deal of abdominal distension.
When considering the question of potency you may have to be a little careful in dealing with old people in Kali carb. cases. Where you have indications for Kali carb. you are not dealing with an acute emergency, and in consequence you do not need your highest potencies. I would give Im’s to older Kali carb.’s for choice. The average case responds well to 10 M’s repeated in the usual way.
| Of the last three drugs I thought of looking at I think Lycopodium probably follows the kali picture more closely than any of the other drugs; it is very similar in many ways.|
In the majority of cases you do not get indications for Lycopodium before the second half of the course of the average pneumonia, in other words, it is not usually indicated until after the fourth day. As a rule, you will get a history that at the beginning of their illness these patients were mentally fairly active, and that they are now becoming very tired, very weary, rather worried about their condition, and not a little frightened.
In appearance, they give you the impression of being anxious; they have rather a worried look, and a practically perpetual frown. They are rather sallow in colour, a sort of yellow-ash-grey appearance, and they have obvious acute respiratory distress. The lips tend to be somewhat cyanosed, very often they are definitely cyanosed, and there may be a somewhat dusky appearance generally. If you see these patients latish in the disease, about the fourth or fifth day, you will find them becoming definitely weak, and rather torpid and sluggish.
The mentality of the typical Lycopodium pneumonia patients is a little difficult to get hold of because although they are anxious, worried about themselves, wanting attention, wanting somebody about, yet they are peevish and irritable with those trying to help them. They are rather domineering, they are definitely exacting in their demands on their attendants, and yet that is coupled up with the desire to get as much attention as they possibly can. After they have been asleep they are very liable to wake up in a very cross-tempered mood.
Associated with the respiratory distress, there is a somewhat pinched appearance of the nose which is not unlike the Antimonium tart. appearance, and there is a good deal of flapping of the nostrils. But there is more general twitching of the facial muscles in Lycopodium, and the nose gives the impression of being dusky, rather than sooty as in Antimonium tart.
Another point about the Lycopodium patients is that they always tend to have a very noticeable yellow discoloration of the teeth. Very often they complain of a sour taste in the mouth, and the tongue tends to be coated white. In addition to this coat there are often definitely sensitive spots along the margin of the tongue, and the patient often complains that it feels stiff and swollen. Lycopodium patient are rather variable as regards thirst. Sometimes you will get a Lycopodium patient who is definitely thirsty, but again you may get a patient who is not thirsty at all. If they are thirsty they prefer warm drinks to cold. And if they have much to drink it is very apt to produce a sensation of fullness and flatulence; it may actually produce a sense of nausea.
The respiration in the Lycopodium case is always very difficult, short, panting, laboured breathing. The patients usually complain of a feeling of tightness in the chest, or even of an actual sensation of constriction.
The cough is always a very difficult, paroxysmal, violent, spasmodic cough. Very often the patient complains of intense rawness in the chest after coughing.
The sputum is always scanty, tough, and very difficult to get up. It is very often a yellowish-grey, blood-stained sputum, and not infrequently the patients tell you that it tastes definitely salty.
As a rule the patients complain of feeling chilly. They are sensitive to cold, but they dislike a stuffy room. Usually there is very little sweating, the skin may be slightly moist but there is no definite sweat. In most of these cases you will find your maximum involvement on the right side of the chest rather than the left. And you will always get a complaint of a good deal of abdominal flatulence, particularly is this so after taking anything in the way of food; the patient feels absolutely bloated on any attempt to eat.
As a rule these Lycopodium patients are very uncomfortable if they are lying on the back, their breathing becomes more laboured, and they are more distressed. They are very much better sitting up.
Another small point is that you will very often see these patients sleeping with their eyes half open, Not infrequently they have a very restless kind of sleep, and they often dream of fatal accidents.
In the Lycopodium case there is one very constant period during which there is a general aggravation of the patient’s – -distress, and that is between the hours of 4 and 8 o’clock in the evening. During this time you will get an increase of temperature, increased respiratory distress, and very often increased cough. Very often the temperature swings up about 4 o’clock, stays up until about 8 o’clock, and then begins to drop.
As regards the temperature in Lycopodium, commonly it is a medium high one, ranging round about 103 degree. The pulse tends to be rather compressible, soft and rapid.
Lycopodium cases respond well to 1om’s repeated 2 hourly.
| Arsenicum is one of the drugs which you will require only in the collapsed stage of a pneumonic crisis; you seldom get indications for it during the active stage of a pneumonia.|
The picture presented by the Arsenicum patient is very typical. There is always intense mental and physical restlessness. In the earlier stages of the collapse you will see the patient constantly tossing about, never still for a moment, and as the collapse goes on he gets weaker and weaker until he is hardly able to move, and even then his eyes keep it up to the very last.
Right throughout the whole picture there is exactly the same sort of mental state-extreme mental anxiety, extreme fear, The patient is certain he is going to die, he wants attention, wants somebody there, is afraid of being left alone, and wishes to goodness you would get on and do something for him.
The appearance of these patients is somewhat suggestive. As a rule they are pale, and rather livid looking, or they may be somewhat cyanotic, and the surface is covered with a cold, clammy, sweat. The lips are usually cyanotic; they may be rather full, but very often you will see them looking rather shrunken, shrivelled looking, and actually bluish.
The patients themselves are always intensely chilly. Very often there is almost a rigor; the patients keep shivering with cold, they want to be covered up, and they cannot bear any draught about.
They are always intensely thirsty, their mouths are parched and dry, and there is a constant desire for sips of water. The strange thing is that in spite of their general chilliness, they want their water as cold as they can get it.
The characteristic thing about the tongue in the Arsenicum case is its dryness. It may be red, or it may be brown, but it is always dry, dry to the touch, and the patient often complains of the mouth feeling burning hot.
Then as regards the cough in these Arsenicum cases, you will very often find the patients hardly coughing at all, they do not seem to have sufficient strength to cough. Any cough that there is is very useless and brings up no sputum at all. If the patients are not quite so ill as that, they have a very violent, suffocative cough which makes them sit up in bed feeling as if they were going to strangle.
They always complain of intense compression in the chest; it feels horribly tight, as if they could not breathe at all. And after coughing, or even when they are lying still, they often complain of burning pain in the chest. After one of these paroxysms of coughing they very often have violent pain round their lower ribs, and very often pain in the epigastrium, too.
The sputum in Arsenicum is always scanty, because, as I mentioned before, the patients do not seem to have the strength to get it up. Very often they cough it up into the back of the throat and just swallow it.
In these Arsenicum cases you are very apt to get a falling temperature; you may get an actual collapse temperature, with a running pulse and possibly a fibrillating heart. And the patients often complain of a horrible feeling of tremendous weakness in the chest.
The collapse in Arsenicum cases is very liable to take place in the early hours of the morning, it is usually sometime between 1 o’clock and 3 o’clock and is most likely between 1 o’clock and 2 o’clock.
Well, that is the picture as you see it. And here I want to put in a word of warning. If you have a case of that sort, with definite Arsenicum indications, and you prescribe Arsenicum and get a reaction taking place, unless you follow that Arsenicum up with another drug within the next twelve hours you will find your collapse recurring ; then you will find that your patient does not respond to a repetition of your Arsenicum and that patient will die. The kind of response you get to Arsenicum is that the intense mental anxiety begins to subside, the intense chilliness subsides, the patient begins to feel warmer and more at peace. The intense sweating stops, the temperature begins to rise a little, and the pulse begins to steady down. Well that is the stage at which you must follow up with your next drug.
You may require any drug in the Materia Medica to follow up that reactive stage, but the two which are very much the most commonly indicated are Phosphorus and Sulphur. If you get your patient becoming warmer, the anxiety going, the pulse improving, the temperature rising,and instead of the white, livid appearance the patient becoming rather flushed, and still remaining thirsty, then the probability is that he is going on to a Phosphorus reaction. If, one the other hand, the response is not quite so complete, the patient is becoming a little warmer and then having cold waves, the anxiety is not quite so great but he is feeling frightfully tired out, he is still a bit sweaty, possibly the legs and feet are a little cold and the upper part a little hot, or possibly the legs and feet are a little hot and the upper part cold, he is intermittently hot then cold and chilly, then the patient is going on to Sulphur. And, as I already said, you will find that in the majority of cases Phosphorus or Sulphur is the drug with which you have to follow up your Arsenical response, and you will find a IM your most useful potency repeated 2 hourly.
|The last of these drugs I want to touch on in detail is Sulphur. There is practically no disease from which humanity suffers in which you may not find Sulphur indicated, and there are various occasions in pneumonia in which you may want Sulphur. It may be indicated in any stage of the disease from the second day onwards. You may want to prescribe Sulphur in one of these difficult cases which is not clearing, one in which you have had indications for a drug which has done a certain amount of good, then you have had indications for another drug which again has done some good, and finally you cannot get clear indications for anything and the patient is not yet well. An intercurrent dose of Sulphur will set up a response. You may get indications for Sulphur in a case in which the patient has done quite well up to a point, the temperature has come down, either by crisis or by lysis, and yet the physical signs are not improving to your satisfaction; a dose of Sulphur will very often clear up the whole thing, start your resolution, or clear up remaining patches in the lung. But these are not the cases I want to cover in the description of the straight Sulphur pneumonia.|