This is, gentlemen, the last lecture I am going to deliver on cholera and its homoeopathic treatment. It is the last, not because the subject has been exhausted, and there is nothing left any more to say, but because I have exhausted all the knowledge on the subject, that is in me. We approach now the considerations referring to the treatment of the stage of cholera collapse, a most serious, complicated stage. Serious, in as much as only ten per cent. of patients spontaneously recover, if we are to believe Dr. Machamarra’s statement on the subject;complicated, because we deal here with a pathological state, the symptoms of which may be either spasmodic, or paralytic in their nature, or a combination of both. All this is so much the more true, the farther the stage of collapse is advanced.
Properly speaking, it is difficult to say, where the stage of collapse begins. It is a stage which is easier recognised as such, than defined by so many words. A low temperature 3 to 4 or 5 and even 6 degree F., below the normal standard, coldness all over, distinct signs of an impeded circulation and respiration, with or without purging or vomiting, constitute the chief characteristics of that stage. As a rule the evacuations are not considerable, the patient being exhausted, or emptied; nausea, retching, and now and then a small discharge of a rice water fluid from the rectum continue, however, often to the last.
That our best remedies will here often fail, is easy to see; we deal here no more with a morbid process; we deal, with an organism injured by a preceding morbid process–and nobody can tell, in how far the injury inflicted is within, or beyond possible repair.
I shall first speak of the condition of the blood. Physically it has become so far altered, as to have greatly lost its fluidity; it has become thickened, tarry, unfit for easy circulation through the minute capillaries of the organism. Physiologically it has experienced another great injury; it has been to a large extend deprived of its vivifying element, of its oxygen. With the serous dejection a considerable quantity of saline matter passes out of the body–another morbid alternation in the chemical constituents of the blood as a whole: although according to Dr. Garrod(* London Journal of Medicine, May, 1849.*) it would appear, that the proportion of water discharged is so much the greater, that the percentage of salts in the blood is rather increased than decreased.
However urgent the indications may be too minister to the functions of the organs of respiration and circulation, we must never, for a moment, loose sight of the grave condition of the blood itself, upon which after all the sustenance of the organs themselves depends. The calming of the irritation of the digestive organs will, therefore, engage our first attention. So long as the patient is not able to take, or to retain when taken, any liquid, so long must be considered not to be out of danger, however distinctly some signs of reaction may have made their appearance. We have seen in a previous lecture, what great advantage we may derive in such a state, from Ricinus and Cuprum. should ever Arsenic be called for in a similar condition, you will find that dilutions between the 12. and the 30. far superior to the lower dilutions. Constant nausea indicates Ipecacuanha, Tart.Emet.., Tabac. or Nicotine at any rate in the case of individuals not given to smoking tobacco. The nausea of Tabac. or Nicotine is accompanied by burning heat about abdomen, the rest of the body being cold and clammy. The patient persists in uncovering the abdomen. There is total indifference to nakedness. Carbolic Acid has done me good service in cases occurring in filthy quarter, infected by bad drainage: I gave the
I must confess I do not like to see Carbolic Acid used as it is done in many houses, as a disinfectant of the choleraic stools. The Carbolic Acid smell is sickening to me, and I believe the patient is similarly affected, although he my not be aware of it.
In all cases where the state of the digestive organs engage our attention on the one side, and the state of some other important organ on the other, I propose that, in order not to neglect either the one or the other, to alternate or remedies, provided we cannot lay hold upon the drug which satisfies all the exigencies of the state present. Or, what I would consider still preferable is this: Let the water the patient is to drink be medicated by such of our medicines, which we consider best calculated, to enable him to retain his drink, and to combat at the same time the nausea and inclination to vomit, if there be any. Again vomiting, the gastric irritations in general might disappear first. The patient might even manifest some desire for some food, while the choleraic discharges are till going on. In such case, we should not hesitate to allow the patient some barley or arrowroot, salted, cautiously to take; while we might administer Veratrum, Crot. Tig. or Ricinus in order to control the stools. In most cases we shall find that the stools are not strictly choleraic under the conditions above mentioned. Sometimes they are watery and colourless, yet no more rice- watery; they appear to be watery mixed up with flakes of mucus. Here we might sometimes substitute with advantage Ol. Ricini 3 to 6 instead or Ricinus,
For the restoration of the function of the blood, as far as its oxygen carrying capacity is concerned, we have or at least we believe to have, one drug is our Materia Medica, of which clinical experience has spoken in very laudable terms. I speak here of Carbo Vegetabilis. It is supposed to act, both upon the blood and the various tissues of system, especially upon those portions of nervous system, presiding over nutrition; it devitalizes the blood and exhausts the nerves, at least this is the explanation given of the various phenomena of depression which its provers have shown to be produced, under its influence, on the organism. These symptoms of depression, let it be understood, have been obtained from experiments made with carbo-triturations. Charcoal in its crude state i n inert substance, void of any pharmacodynamic action. Triturated, it has however been shown by Hahnemann and his disciples to have pharmacodynamic powers in the direction mentioned. This is a matter of fact, and all what a priori-argument can ever say against it, will not affect us, who know, from other instances, that Carbo Veg. does not stand alone in this respect. Vegetable charcoal, in triturated form, has been used in our school against complaints connected with old age, with low fevers, and all such disorders, where the oxydation of the blood is known to be faulty. I cannot tell you who first hinted, that it should be tried in the stage of cholera collapse; but it was a very happy hit indeed. Both Baehr and Kafka speak highly in its favour, and I may as well contribute my own small share to the statements of others. Carbo Vegetabilis, says Dr. Baehr, has done us not infrequently good service at a period of the cholera process, where most of us are at a loss how too lay hold upon an effective remedial agent. It is indicted at the asphyctic stage, when vomiting and purging have ceased, when there are no cramps any more, the patient lying moreover extremely prostrated– corpse-like. Carbo follows often well after Arsenic; more frequently, however, it suits in case void of reactionary signs from the very beginning.
It is worth while noticing, that the effects of carburetted hydrogen closely resemble the asphyctic stage of cholera. In Allen’s Encyclopaedia, article Carboneum Hydrogenisatum, we read actually that it has produced in one man exposed to the gas rice- water stools, for sometime after the attack.
Carbo Vegetabilis produces haemorrhage from the bowels–a condition not very rare in far advanced cholera patients, the intestinal mucous membrane of such patients being in congested state. We have seen the benefit we may derive in such a contingency from Mercurius Corrosivus, or Ricinus when the discharge is more or less like bloody serum; Phosphorous should here be remembered and in connexion with typhoid symptoms-Rhus Tox; a discharge of a brown fluid would indicate Phosphorus.
Similar good results may be expected from Carbo Vegetabilis when the discharge consists of pure blood, oozing out of the rectum. Fetid discharges from rectum would also point to Carbo. Veget. Bloody serous evacuations during the reactionary fever point to Rhus Tox. It may be that it is in cases where there is internal haemorrhage that we derive most benefit from the administration of the drug in the stage of collapse.
I see Dr. Raue recommends Argentum Nitricum amongst other remedies in the stage of collapse, when dyspnoea is excessive owing to spasms of the respiratory muscles–a sort of dyspnoea the drug never produces, and a dyspnoea which is not frequent in the last stage of cholera; should it occur, then we have in Hydrocyanic Acid a far more reliable, and by far more promptly acting remedy, than in the nitrate of silver. This drug has been shown by the late Dr.V.Grauvogl to deprive the blood of its oxygen-carrying capacities; and Dr. Boglowsky’s subsequent experiments on animals fully confirm Dr. Grauvogl’s assertions. The salt has a direct and primary action on the red blood- corpuscles, causing their colouring matter to escape into the plasma. This is just what is taking place in cholera; and it is owing to this process that the blood of cholera subjects is found to be black, tarry. I should strongly recommend Argentum Nitricum in a low dilution, say the 3 decimal, wherever the dyspnoea is by far greater, than the state of the heart and the lungs could justify us too expect; in other words whenever we have ground to believe that the respiratory function of the blood is more damaged, than that of the respiratory organs themselves. This may, however, remind us of Hydrocyanic Acid or its salts (Kali Cyanatum or Sulphocyanide of Potass), or again of the snake poisons.
As to the action of remedies in the state of collapse, it is often surprising with what promptness they do act. It might almost be said, no stage is too far advanced as to be pronounced entirely hopeless. But rarely do we find more than a transient benefit as the result of our therapeutic efforts, in advanced stages. To the gravity of the situation there is superadded another difficulty with regard to medical treatment–the difficulty how to select the right remedy. During the progress of a disease the symptoms characterising the pathological condition of the patient are of a positive order; while in the stage of collapse most of the symptoms are negative in their character; and even these negative symptoms are by no means easy to interpret.
Having already spoken in former lectures of the various remedies which may be particularly called for in the cholera- collapse, very little remains for me to say regarding their respective indications beyond reminding you that we meet sometimes with cases where after the choleraic discharges are suspended there is a passive, involuntary oozing out from the rectum of a watery fluid of brownish or pale yellow colour, for which case Phosphorous will be found most useful, I distinguish before all between such cases where respiration is carried on with effort, however ineffectual those efforts may be; and between such others, where the respiratory act is carried on, in a more or less slovenly indifferent manner. In the first case the respiratory centres and the pneumogastric nerves are still in full vigor. The dyspnoea arises then, either from the incapacity of the blood to benefit by the act of inspiration; or from the heart being too weak and inefficient in its action, to keep up the pulmonary and systematic circulation; or, finally from some spasmodic interference with the act of respiration.
Suppose, the heart still to be in a comparatively efficient state of action; suppose, at the same time, there is no ground to attribute the dyspnoea to spasmodic disturbances, (the respiration being simply superficial without being laboured) then we are entitled to conclude that the respiratory troubles are solely owing to the incapacity of the blood to assimilate the oxygen supplied. In this case we shall prescribe argent. Nitr.; reserving Carbo Veget. for such conditions where no respiratory efforts are made by the patients; in which case we might also think of Ether.
But suppose we find the heart’s action altogether weak, unequal to its task, then we shall resort to Aconite; a drop of the mother tincture (some would insist that the tincture of the Aconite root should be used) in about three ounces of water, of which a teaspoonful is to be taken, every five to thirty minutes, according to the circumstances of the case.
We administer Aconite when the beats of the heart are regular; it is most suitable in the case of young people of robust constitution. There is anxiety, fear of death, a stupified childish expression of the face, much talking and lamenting, although the case on the whole does by no means look so desperate as patient thinks.
Under similar conditions we may use Camphor, should we be called to see the patient after he had been drugged by allopathic medicines. There is less anxiety about the patient, although the struggle for breath may be more pronounced. Presence of spasms, trismus; cold, clammy sweat all over the body; no vomiting, no purging. Spasmodic cholera variety prevalent.
Arsenic is called for in any cholera variety, characterised by great anxiety, constant restlessness; great oppression of the chest. Paralysis of the heart, even in animals poisoned by arsenic, is preceded, according to Lesser, by slight and transient increased irritability, accelerating the heart’s beats. The irritability plus depression is certainly very prominent in arsenic poison, and hence served as clinical indication. We should, however, not forget, as our school seems to have done, that want of irritability is no counter indication should Arsenic otherwise be indicated. Hahnemann in his lesser writings points to arsenic and the calmness of the victim. Oxylozon cases given above point to the same direction. Great irritability associated with extreme prostration, distinguished Arsenic from any of our drugs. Cardiac action is accordingly found to be more or less irregular.
Hydrocyanic Acid, or Cyanide of Potassium does not yield to Arsenic as far as the great struggle for breath is concerned. In Arsenic it is the inspiration which is impeded, in Hydrocyanic Acid it is particularly the expiration which is spasmodically obstructed. In Arsenic difficulty of breathing–there is spasm of the bronchial tubes–consequently difficulty of inhaling. Hydrocyanic Acid has generally been used as a last resource, when the patient had not been benefited by the usual remedies; in this way, the drug was reserved for such advanced cases where the patient is pulseless; altogether more dead than alive. Strange to say, even then a man would now and then actually be taken out of the jaws of death by the administration of Hydrocyanic Acid. By means of the before-mentioned characteristic of the Hydrocyanic Acid-dyspnoea, you will know how to make use of the drug in an earlier stage of collapse, and have therefore more chance of saving your patient. The respiratory centres under the action of the drug under consideration, are fully active to the last; there are deep inspirations, far deeper than is ever the case under the action of Arsenic, where all functions at the last moments are carried on under the impulse of an inefficient excitement. In Hydrocyanic Acid it is especially the expiration that is labored and inefficient. Breathing is altogether slow. This sort of respiration is also characteristic of Secale Corn. The spasm of the diaphragm seems to be the chief cause of the slow respiration. Anxious breath, sighing and hiccough, points to Secale. The excitement Hydrocyanic Acid produces on the spinal cord causes often tetanus a state we seldom meet with in the last stage of cholera. But there is a certain spinal excitement, because of the spasm of the rima glottidis, similar to what occurs in chlorine inhalation, often manifest at that very last stage, which takes us by surprise. I have already spoken at a previous occasion of the attempt on the part of such patients to leave their bed and move about, in spite of their extreme prostration. Whenever such an attempt arises from a mere excitement of the motor centres, then the determination to move about is likely to be by far stronger, than the actual capacity to carry it out. It is in such cases that I recommended Cuprum. But we often find such patients actually gathering strength, getting up, and aimlessly walking about, stopping only short every time they want to take a deep breath. The irritation in their case is spinal; and Hydrocyanic Acid will often subdue both the irritation of the cord and the spasmodic oppression of the chest. There is, however, yet another sort of restlessness to be mentioned that has often, in the hands of unobserving practitioners, caused them to administer Arsenic, while Arsenic was in reality not called for. I allude here to that restlessness and tossing about of a patient caused by a choleraic stool being retained for a time within the intestinal canal, owing to paresis of the intestinal muscular coat due to some spasms of the sphincter ani, or to some deficient sensibility on the part of the large intestines towards the accumulated rice-water secretions. Such patients are quiet after the stool is passed. It is not anxiety, but inconvenience that makes them restless for a time and Arsenic has nothing to do with the case. The remedies recommended for diarrhoeic cholera should in such cases be adhered to. Paresis of the intestinal muscular coat points to Nicotine, but Nicotine has no restlessness, rather indifference and total depression. Again it may happen that vomiting and purging suddenly cease, when sudden collapse makes its appearance, instead of the hoped-for improvement. In such as case give Hydrocyanic Acid.
I should like very much to see in such cases Muscarin tried. Restlessness and constant desire to get out of bed, we all know, is a characteristic of Agaricus Muscarius; it is owing to excitement of the motor nervous, and is accompanied by increased muscular force. It produces besides great constriction of the chest. But the analogy between it and cholera does not stop there. Let us hear what Lauder Brunton has to say about Muscarin. Muscarin affects especially the heart and intestinal canal; it produces uneasiness in the stomach, vomiting, purging, a feeling of constriction in the neck, want of breath, giddiness, fainting, prostration and stupor…. respiration is depressed in proportion to depression of the pulse…. It lessens urinary secretion, even to the point of suppression; it contracts the pupils… Muscarin has a singular effect on the pulmonary vessels. Schmiedberg had noticed that Muscarin produces intense dyspnoea, a condition in which the arteries contain very little blood, scarcely bleeding when cut across. This dyspnoea has been shown by experiments on rabbits to be due to the Muscarin causing strong contraction of the pulmonary blood-vessels, so strong that the lungs become blanched, and, owing to the contracted state of the pulmonary blood-vessels, the right side of the heart becomes greatly distended. [* Dr. Ringer’s Handbook of Therapeutics*). Now this is just a state as Dr. Goodeve found to be characteristic of cholera, and by which the asphyctic stage of cholera is marked and distinguished from the usual, gaseous asphyxia. I am not aware of any drug of which we could positively say that the dyspnoea it produces is due to contraction of the pulmonary vessels, with the exception of Muscarin and Nicotine. Concerning the latter drug we have the testimony of Dr. Richardson in his book on Modern Diseases, a book I have not just before me.
Muscarin has a second stage which may not less find its counterpart in some modes of cholera-collapse. In the fifteenth volume of Ziemssen’s Cyclopoedia, Dr. Von Boeck writes concerning this drug : The action of this poison generally sets in with more or less violent colic, accompanied with vomiting and subsequent diarrhoea. It is left to clinical experience to decide in how far this succession of symptoms may serve as a guide in the treatment of cholera cases. These symptoms are added to arterial disturbances : the patients think they are drunk, become violently excited. Then a state of sopor gradually sets in, in which the excitability of the sensory and reflex nerves is more or less lowered and quite destroyed. The pulse is as a rule retarded, the arteries are constricted, the pulse becomes threadlike, the respiration is generally short and stertorous, the pupils are dilated, the extremities and the features are cold, and death may supervene from progressive loss of cardiac power.
Muscarin should certainly prove a great remedy in the cold delirium occurring sometimes in cholera collapse. Carbolic Acid produces collapse with delirium (see Burton’s Pharmacology p. 737) and should have the first trial in all such cases, where delirium and not motor excitement is the chief symptom accompanying the collapse. Arsenic, Camphor and Cantharides are, each of them in their own way, homoeopathic to cold delirium. As to Arsenic it need only be mentioned here that delirium is one of the symptoms which we find often mentioned by Allen in cases of poisoning. Clinically I should advise Calcarea Arsenicum where cold sweat on the forehead is prominent; Antimonium Arsenicum when the delirium is associated with dyspnoea. Camphor is characterised by clammy sweat all over. Canthar. if the delirium either is quiet bordering on coma, or that there is a sign of setting in or having set in of uraemia. On the whole I think we should not leave Muscarin untried in some of the phases of collapse to which it is undoubtedly homoeopathic. Remembering that Agaricus Musc. is homoeopathically indicated and has clinically proved useful in various disorders affecting drunkards, we should think of Muscarin in cholera cases of habitual drunkards. It is so difficult to break through routine practice. Muscarin deserves a place next to Veratr. Alb. I should say, in diarrhoeic cholera. It is worth noticing as an indication of our toxicological ignorance, that Atropine antidotes Muscarin, while it does not antidote cholera.