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.
Rhus tox.
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.
Natrum sulph.
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.
The tongue in Natrum sulph. is very suggestive. It has a pretty general greyish-green coating. At times you may find a yellowish tongue with a definitely brown base, or a whitish tongue with a yellow base. But that greyish-green tongue is the one characteristic of Natrum sulph.
The patients always complain of a good deal of acute pain in the chest, and it is a pretty acute stabbing pain accompanied by a feeling of general soreness in the chest wall. That stabbing pain is very much aggravated by coughing, and while coughing you will find these Natrum sulph. patients sitting up supporting the side of the chest to keep it as quiet as possible.
There is always a degree of physical restlessness in Natrum sulph. patients, they feel jolly uncomfortable, they are forced to change their position, but their movement does not give them any sense of relief at all.
Then all the Natrum sulph. pneumonias I have seen have complained very bitterly of an intensely troublesome occipital headache.
There is usually a rather bitter taste in the mouth, but the thirst is not extreme.
Another symptom which is sometimes very distressing is a feeling of intense heat in the legs, from about the knees downwards. You know the ordinary Natrum sulph. time of aggravation is taken to be about 5o’clock in the morning, well, in their pneumonias that is not the time of maximum aggravation, it is much earlier, it is between 3 and 4 o’clock in the morning. You are liable to get a very bad spell in these Natrum sulph. pneumonias about 3 and 4 o’clock in the morning, definitely earlier than the 5 o’clock aggravation that you expect in Natrum sulph.
As regards the sputum, quite frequently in these Natrum sulph. cases it is definitely greenish, and it may even be definitely bile-stained. One winter we had quite a number of cases with frankly bile-stained sputum in their pneumonias. And with that greenish, or yellowish, sputum there is a good deal of rusty material inter mingled. There is a fair quantity of sputum, and as a rule it comes up without undue difficulty.
He wrote a number of books: Children's Types, Digestive Drugs, Pneumonias
Douglas Borland died November 29, 1960.