Books » Borlands Pneumonias by Borland, D.M. » Incipient Stage

Incipient Stage


Role and indication of Aconite, Belladonna, ferrum phos. and ipecac in hte cases of Incipient Stage of pneumonia by D.M Borland.


Aconite

In the Aconite pneumonias you will always get a history of a very sudden onset. Usually the story is that the patient has been out and exposed to cold, and the same evening he comes down with a temperature-it is a very acute, rapidly developing condition. You are much more likely to meet with it in the strong, healthy, robust patient. As a rule you will find a high temperature, very marked excitement, restlessness, and pretty acute anxiety. The patient has a full, bounding pulse, a very flushed face, and a hot dry skin. Usually he complains of a very dry mouth which feels hot and tingling and is accompanied by intense thirst. The desire is almost always for cold drinks.

Well, that is the picture as you see it. And, of course, on that you cannot make your diagnosis; you cannot decide whether the patient has an ordinary chill which will subside in no time, or whether it is going on to a definite diseased condition.

Then to take up the points that lead one to prescribe Aconite. With this intense excitement, restlessness and anxiety, in your Aconite patient you find you have contracted pupils. That is the first point you have to fix on from the prescribing point of view. The next point is that, in spite of the extremely hot, flushed face and hot skin, your Aconite patients complain of coldness of the extremities.

Another point which is an Aconite indication is that the patients very quickly develop a constant, dry, short cough, which they say is due to the dryness of their throat. Very early they begin to have pains, pretty acute stabbing ones, usually in the left side of the chest. If you see your Aconite patient after the first twelve hours you can usually make out early signs at the left apex-that is where you get your first definite clinical indication that the patient is starting a consolidation. And here a distinguishing point comes in; the Aconite patient with definite early involvement of the left side of the chest is aggravated by lying on the affected side, he is more uncomfortable turned over on the left. The most comfortable position is well propped up lying on the back.

Very early, if the patient is developing pneumonia, he begins to bring up small quantities of sputum which is streaked with bright blood, and with the effort of coughing he feels as if his chest were being cut.

If you see the patient within the first twenty-four hours, or possibly within the first thirty-six hours, you will find these Aconite indications, but if it has gone on beyond thirty-six hours at the outside you will not get your response from Aconite. Nor will you get Aconite indications. If it has gone beyond the Aconite stage there will be definite patches of consolidation in the affected lung and you will get no response to Aconite, you will have to go on to one of the drugs for the later stage of pneumonia.

That is the typical Aconite onset. And here I think it might be worth while discussing dosage and repetition in these incipient pneumonias, because the same applies to all four drugs.

In these acute conditions, if you want to abort the attack altogether it is no use prescribing under a 30. If you give 3x of Aconite you will modify the temperature, you will modify the distress, you will modify the anxiety, and you will modify the pain. But you will not arrest the progress of the disease and when you go back and see the patient next day you will be able to make out definite physical signs in the chest. If you give potencies above the 30, when you go back next day you will find that the temperature has fallen and all the symptoms are subsiding. The whole thing just fades out and you will think you have probably made a mistake in your diagnosis and it was merely a common or garden chill and was never going to be a pneumonia at all.

If you have simply an Aconite chill, which has not yet developed a raging temperature, Aconite low will do away with the effects But a 6, for instance, will only do it if you get in very early. Once your raging temperature has developed you must give a high potency if you want to abort pneumonia. If you have simply an irritation from exposure to cold Aconite wipes it out; say the patient has a temperature of 99 degree, a dose of Aconite in any potency will stop it. But if the patient is heading for a pneumonia Aconite 6 will not do it- I have seen it tried.

If you are using potencies above a 30, I think you are wise to repeat your medicine at not longer intervals than one hour for the first four hours, and after that keep up your administration at two hourly intervals over a period of twelve hours in all. If you do that, and your prescribing is accurate, you will see case after case in which you have obvious physical signs starting, which from your experience you know would be a commencing pneumonia, but which in twenty-four hours is perfectly well-you simply abort the whole thing. This applies to all four drugs for incipient pneumonias. The administration must be kept up until the temperature is right down, otherwise it is very liable to swing again.

The 30 also works but it works more slowly; you will abort these cases with it, but not in twelve hours, you will have to keep up the administration longer. At the end of twelve hours you will not be satisfied that the patient is well; he will be obviously on the way to recovery, but you will have to keep up the administration for at least another twelve hours.

Ferrum phos

The next most common of these early drugs is Ferrum phos. The Ferrum phos, picture also is fairly definite. As a rule, the pneumonia takes a little longer to develop than in Aconite. For instance, if you get an exposure one afternoon you are unlikely to find the Ferrum phos. picture developing before the following morning. And you may get Ferrum phos. running on to about the third day of disease, until you have definite, obvious consolidation.

The first distinguishing feature between the Ferrum phos. patient and the Aconite is the appearance. Instead of the very brightly flushed face and hot, dry skin of the Aconite, in Ferrum phos. you usually find either a localized flush over the malar regions, or else a very variable state of redness, that is to say if the patient is coughing, is disturbed, or has to talk, he very rapidly flushes up a bright red flush, but when he rests that flush tends to ebb away and leave just the malar flush on a rather palish background. Also in Ferrum phos. you often find a very suggestive pallor round the mouth.

The next thing about Ferrum phos, is that you do not find the same degree of excitement and terror as there is in Aconite. The patients are more tired, they are very indisposed to talk, they are very sensitive to any disturbance round about them, any noise, and loud speaking seems to distress them, and they want to be left quiet. They are very much more at peace if they are quiet and if no interferes with them-which is exactly the reverse of the Aconite state in which the patient are terrified, want someone to be about all the time, are sure they are going to die, and are afraid to be left alone.

As regards temperature and pulse rate, it is very difficult to distinguish between Aconite and Ferrum phos. Both run a high temperature and both have a rapid, bounding pulse.

Where thirst is concerned there is very little to it also. They are both very thirsty, and both want quantities of cold water. But occasionally you come across Ferrum phos. patients who complain of rather a sweetish taste, and instead of wanting cold water they prefer something rather sour to counteract this sweet taste.

The tongue in Aconite and Ferrum phos. is different. In Aconite it is usually dry, and not particularly coated. In Ferrum phos. it gives the impression of being somewhat swollen. At the commencement it is usually red, although it may have a faint white coating; by the third day it will have developed a definite coat. But in the earlier stages it is a rather darkish red, swollen looking tongue.

The Ferrum phos. patient has a pretty incessant, tormenting cough, but, instead of being induced by a sensation of dryness in the throat as in Aconite, it is excited by a sense of irritation lower down behind the sternum. Very frequently you get a history that if the patient has a violent about of coughing it is very liable to bring on an attack of epistaxis.

There is another constant point about the Ferrum phos. patients, and that is that in their febrile attacks they are definitely chilly. They are sensitive to cold, and their cough is liable to be excited by a draught of cold air.

Another point that distinguishes Ferrum phos. from Aconite is that the right side of the chest is much more likely to be involved than the left. You very often find pleuritic signs on the right side quite early in the disease, it is not at all unusual for a definite pleuritic rub to develop within forty- eight hours of the onset, and with that pleuritic rub you are liable to get the development of very sharp pleuritic pains, which, of course, are aggravated by motion. Apart from their pleurisies your Ferrum phos. patients are often restless, but once they have developed a pleurisy any movement hurts them.

A further point which sometimes helps you is that the time of aggravation in Ferrum phos. tends to be in the early morning, usually between 4 o’clock and 6 o’ clock, whereas the Aconite time of aggravation is late in the evening, sometime up to midnight.

The character of the sputum is a help, though not so much in distinguishing between Ferrum phos. and the other acute drugs as between Ferrum phos. and Phosphorus with which it may easily be confused. In the Ferrum phos. cases you are liable to get a bright red streaked sputum, rather than the rusty sputum of the later pneumonia drugs, in other words Ferrum phos. is indicated in the early stage of consolidation. The Phosphorus sputum on the other hand is beginning to turn rusty, it is a darker red and there is more blood in contrast to the streaky sputum in Ferrum phos.

Belladonna.

Here again you have a very clear cut, definite picture. The onset of the Belladonna attack is just about as acute as that of Aconite. You often find a Belladonna case developing the same evening as the patient has been subjected to exposure. The attack is always very severe. It is attended by a violent temperature, running up to 105 degree or over, with intense excitement of the heart, and a pulse which feels as if it would almost burst through the vessels. The patient is always extremely excited, and I have seen these Belladonna cases, particularly in children, in which the patients have been practically delirious within twelve hours of the onset of the disease, with the temperature running up to 106 degree. They always have a bright red face, and very often you will find a generalized blush over the whole skin and the surface burning hot to touch.

If the patients go on to the delirious state-or possibly even short of that-you always find intense excitement in Belladonna It is not the extreme anxiety and fear of impending death which you get in Aconite. It is a question of excitement; and in the adult the Belladonna case is the type which comes into hospital and Sister reports: “I will have to get a special for this patient, I cannot keep him in bed, he is restless, excited and crying out, and almost impossible to control.”

The next thing which distinguishes these patients is the state of the pupils, which in Belladonna are always widely dilated. You can tack on to that the Belladonna photophobia, which is intense; these patients are invariably sensitive to light. If you are nursing a Belladonna pneumonia you are tempted to keep a light in the room as the patient appears to be terrifies of all sorts of things, but, if you do, for goodness sake do not let it shine on your patient. They seem to see strange things in shadowy corners, and one feels one must keep the light on to let them see what is there, but it is absolutely essential that it should not shine on them. This is a very useful distinguishing point, because some of the other drugs have a similar condition in delirium, but they hate to be in the dark and want the room lighted as otherwise they imagine all sorts of things in dark corners. Belladonna patients always prefer to have the room darkened because of their photophobia which outweighs all else.

Then as regards the thirst, Belladonna patients always have a dry mouth. It is always laid down in the textbooks that Belladonna is intensely thirsty, but I have seen quite a number of Belladonna pneumonias in which there was very little thirst at all; the patients complained of the mouth being very dry, hot, and burning, and yet they were not particularly thirsty. So do not be put off Belladonna because the patient is not as thirsty as one would expect from the statements in the textbooks.

In the pneumonias you do not get the typical strawberry tongue that is described in Belladonna; you are much more likely to find a congested, dry, dark red tongue.

I think a right-sided pneumonia is more common in Belladonna, but I have seen cases with the main involvement on the left side. The thing that is constant about them is that any movement of any kind is liable to bring on an attack of coughing. In the early stages, the Belladonna cough is a very dry, painful, tearing cough, and the sputum is usually very scanty indeed.

These patients always have a very intense, congestive throbbing headache, which is worse if they are lying with the head at all low, and is frightfully sensitive to any movement.

Another symptom of Belladonna which is sometimes helpful is that the patients are very liable to develop an acute hyperaesthesia of the chest wall over the affected area. The chest wall becomes astonishingly sensitive to touch, and is horribly painful on coughing. And, because of this hyperaesthesia of the chest wall the patients are unable to lie on the affected side.

Ipecacuanha.

The fourth of these drugs for the acute stage of pneumonia is Ipecac. and it applies much more to children than it does to adults. I do not know if you were taught, as we were that 80 percent. of children’s ailments start with an attack of vomiting, no matter what the child is going to develop. I think it is very nearly true, with the results that many of these children with a commencing pneumonia, or possible even more commonly with a commencing broncho-pneumonia, show very definite indications for Ipecac.

In my experience the onset of the Ipecac. pneumonia is a little slower than it is in the other three drugs. One usually does not find clear-cut indications for it under about twenty-four hours. The story you are given is that the child has been seedy the previous day, off its food, possibly feeling rather sickish, or it may actually have vomited. And I think Ipecac. is more commonly indicated in the milder weather than in the intensely cold weather.

In a pneumonia attack the typical Ipecac. child usually tends to be flushed. It is rather a dusky flush, and the child has a hot sweaty face. The temperature in Ipecac. is usually not so high as in the other drugs-it is round about 103 degree-and the pulse is not quite so bounding.

Always in these Ipecac. children the thing strikes you is the amount of mucus in the chest; there is mostly a diffuse, generalized rattle. And invariably the patients have very suffocative paroxysms of coughing. The point that makes you think of Ipecac. is that these suffocative attacks of coughing very often go on to definite retching and the child brings up a quantity of stringy difficult, blood-stained sputum. One has to distinguish these attacks from those found in some of the later drugs. In some of the Resolution pneumonias you find similar suffocative coughs, which again go on practically to vomiting, but in them the patients bring up quantities of dark, offensive blood, whereas the blood in the Ipecac. sputum is always the bright red of a commencing pneumonia.

After these paroxysms of coughing you often find the Ipecac. patients very exhausted, and then their flush disappears and you get the typical pallid, whitish, pale-lipped Ipecac. patient. You get the impression, after these attacks, that the patients are very tired, very wearied, and during that stage they are awfully difficult to please. They feel rotten, they feel sick, they do not want to be fussed, and they may ask for something, but they do not really want it and will refuse it if they get it, they are just miserable.

In their pneumonic attacks these Ipecac. patients always have a good deal of nasal irritation, with pretty violent of sneezing. I have never seen an Ipecac. pneumonia yet which did not have these sneezing attacks.

The appearance of the mouth is somewhat suggestive. It is usually rather sticky, and I have seen two different types of tongue in these cases. In a straight-going lobar pneumonia I think more commonly the Ipecac tongue is clean. But in a broncho- pneumonia, where there is probably a good deal of nausea apart from that caused by the actual attacks of coughing, I have seen an Ipecac. tongue which was pretty heavily coated. As a rule these Ipecac. patients are completely thirstless.