The restlessness in the cold or reactionary stage of cholera is however not always of spinal origin; often it is reflex, proceeding from intestinal irritation; and may even be accompanied by cerebral symptoms. This state is often met with in children. Cina is here the great calmer, whether there is a history of worms connected with the case or not.
And there is one other drug worth mentioning in connexion with general restlessness; it is a drug rarely called for so long as the choleraic state with its grave symptoms is prevalent, but so much the more indispensable at the stage of partial reaction. I speak of Cina. The restlessness in such cases is owing to reflex irritability, starting from the abdominal viscera and spreading over the cerebro-spinal system. Children are most liable to this sort of irritability resembling meningitis. They toss and roll about-either the whole body rolling from one side to the other, or the head only; are exceedingly peevish; do not want to be touched or spoken to nor to be approached even; they cry out in sleep and awaken every now and then from a short slumber in a state of anxiety; feel nauseous or vomit slimy matter, pass watery or slimy stools, often accompanied by profuse irritation, and are cold in the face after the body has already resumed its natural temperature; to judge from the touch–all Cina symptoms. And this is often a group of symptoms we meet with after the choleraic attack is over and reaction is expected. A history of worms is so much the more pointing.
We administer Lachesis or Naja Tripudians (Cobra) when respiration quickens, becoming at the same time more and more superficial, while the heart’s action is normal, and still comparatively vigorous. This sort of respiration is a sure sign of impending paralysis of the respiratory centre, and coincides in so far exactly with what occurs under the venomous influence of snake poison. Sometimes it may not be the centre that is affected, but the laryngeal nerve may become paralysed (comp. note p.3.) in which case Naja should have the preference, as it has a specific paralysing action on the larynx. Dr. Sircar on the strength of some faulty theories, asserted some years ago (see my Medical Controversy 1869) that he has seen good results in some cases from the administration of Cobra in the algid stage of cholera. The patients in his cases may have been suffering from laryngeal paralysis. Difficulty of swallowing, as a sign of setting in glosso-pharyngeal paralysis, may perhaps give us the first warning of a threatening laryngeal paralysis (see p.3).
Whenever there is dyspnoea without any proportionate efforts of respiration, there we may be sure, that the respiratory centres are involved in a state of impending paralysis. Usually we find at the same time the brain similarly affected. Tartar Emetic is here clearly indicated, as I have fully explained in the previous lecture. How far Antimonium Arsenicosum may be of use in some undefined cases, standing between Arsenicum and Tart. Emet. experience alone can teach. Ether should in such a case be thought of, not as a stimulant but as a homoeopathically acting agent (see note p. 225). I can give no particular indications for Nicotine; it appears to me to be in many respect similar to the paralytic stage of cholera collapse, taking especially into consideration what I mentioned before with regard to Dr. Richardson’s remarks. I should administer it whenever Tartar Emetic fails; especially if the comatose state is not associated with cerebral paralysis. Tympanites would be an additional indication. I believe I have already stated, that it is Dr. Buchner who pointed to Nicotine in the so-called paralytic stage of collapse.
The administration of Ammonia by old school practitioners is an unconscious piece of homoeopathic practice, as I have pointed out some years ago.
The stimulant property of this drug is so well established, and so often made use of in practice, that the rationale of its physiological action on men and animals, is quite put out of view. and entirely left to works on toxicology. When we, however, refer to these works, we come to learn quite a different tale about the heart-stimulating power of Ammonia. The experiments of Mr. Blake as quoted by Christison, show that Ammonia introduced in large doses into the veins, acts by suddenly extinguishing the irritability of the heart. Small doses first lower arterial pressure from debility of the heart’s action, and then increase it by obstructing the systemic capillaries. When injected into the aorta from the axillary artery it causes great increase of arterial pressure, owing to the latter cause, and then arrests the heart while respiration goes on.
Ammonia might then be of service to us, homoeopaths, in cases where the heart’s action begins to fail, while respiration is still, comparatively speaking, in tolerable order. Its indications are in this respect the opposite of those of Lachesis or Naja.
In impending cardiac paralysis with great somnolency-in the pure type of paralytic cholera collapse–we may find, besides Tart. Emet. and Nicotine another suitable remedy in Chloral. I can give no special indications.
Concerning the various cerebral symptoms during the state of collapse some of them may be owing to localised hyperaemia, others to localised or general anaemia, other again to impending paralysis. The absence of urinary secretion and the consequent uraemic poisoning is however by far the most important factor in the cerebral disturbances as seen in cholera patients. It is generally supposed that uraemic symptoms are likely to set in during the stage of reaction; but in grave cases there is no saying where collapse ceases and reaction begins. The thermometer might show a rise of temperature; but yet, if we look upon the patient as a whole, we could hardly say he is so much the better for it. In fact a rise of temperature may often be a forerunner of that post-mortem rise of temperature, of which mention has been made in the second lecture. But even where this is not the case the rise of temperature may be a mere depression of an attempt towards reaction, than a wholesome reaction; the gradual return towards an equable circulation being interfered with by congestions in different vital organs : the brains, the lungs, the abdominal viscera, the kidneys. The secretion of urea which had been in abeyance during the purging and vomiting period, is beginning to be re-established, but there is yet no outlet for it, for the urinary organs have not yet adequately taken up their suspended function, and so it may come that, instead of gradually improving, the patient sinks again in a comatose state, with delirium and even convulsions. Vomiting may set in afresh under such circumstances. Now the gravest mistake you can ever make in such cases is, to recur to such remedies as Opium, Belladonna, Hyoscyamus, Stramonium and I add, without hesitation, Cantharis. None of these remedies has any direct action on the blood; they have each of them a specific local action, and may as such prove useful as auxiliary remedies, but are unable as such to cope with a disorder that is the expression of general exhaustion and impaired organic nutrition.
I must refer you for all further considerations on the subject to Dr. Buchner’s Essay on Bright’s disease, and shall content myself to say that he considers Arsenic as the foremost remedy in the comatose, Cuprum in the convulsive, and Hydrocyanic Acid and Nicotine in the asphyctic form of uraemia. Cuprum Arsenicosum 2nd or 3rd decimal trituration has shown most favourable results in convulsive uraemia. Ammonium Carb. is another remedy to be remembered. There is drowsiness. large rales in the lungs, cyanosis. All this apparently reminds of Tart. Emetic but this drug is no haematic poison, and should give place to Ammonium Carb., which has a decided action on the blood, over and above the symptoms it shares with Tart. Emetic. To this i would only add Carbolic Acid. According to Dr. Brunton Carbolic Acid appears to be a powerful poison to all the tissues, paralysing both muscle and nerve, without previously stimulating them. it should therefore be our great remedy in the collapse of paralytic cholera. I cannot speak from experience, but I venture to predict that it will clinically prove useful, where Aconite and its before-mentioned congeners fail. After death, the blood of Carbolic Acid victims is found to be very tarry, and its coagulability greatly diminished. A study of Carbolic Acid in the Cyclopoedia of Drug Pathogenesy, will persuade every one that we ought to have made better use of the drug than we have hitherto done. Even in the collapse of diarrhoeic cholera I should say Carbolic Acid should prove useful where Carbo. Vegetabilis fails. It should, however, not be administered in the collapse of spasmodic cholera, unless such remedies as Camphor, Tartar Emetic, Cuprum and Cuprum Arsenic or Hydro. Acid have failed. And this should even be the case with regard to Carbo. Veg. From the afore-mentioned Cyclopoedia it is to be seen that Carbolic Acid has the great centre of organic action : the brain, the lungs and the kidneys. It has altogether a great resemblance to Tart Emet. and should be a helpful complement to the latter drug. Antipyrine and Antifebrine look, both of them most temptingly as claimants for the treatment of choleraic collapse; but neither of them has any directly injurious action on the blood. They act on the caloric and respiratory centres, and should, therefore, clinically stand far below Carbolic Acid or Tart. Emet. if they are entitled at all to a place amongst choleraic remedies. i have tried Antipyrine twice with no result. In some malarial fever cases where the temperature varied every day between 92 degree F. and 105-6 degree the administration of Antifebrine 3X gradually regulated the temperature on both sides, while Carbo. Veg. did nothing. Knowing this, there is hardly any ground for us to drop our cholera remedies just at the most critical moment, and to run off with such symptomatic drugs–I cannot call them remedies in our present case–as I have enumerated above. The difference between Arsenic and Cuprum is clearly understood by the very statement that the one is useful in the comatose, the other in the convulsive form. With regard to the two other drugs mentioned, I quote here from Dr. Buchner :
Nicotine and Prussic Acid are very nearly alike in their asphyxiating power, suspending the oxygenation of the blood; but the result to this inanition of oxygen differs according to the organs homologous to each of them. The want of oxygen expresses itself first, and especially with Hydrocyanic Acid in diminished energy of the activity of the heart. The beat of the heart is accelerated with a full and soft pulse and with a gradually slower and weaker motion of the blood, stagnation of blood follows in the heart and lungs, palpitation with indescribable anguish and oppression of the chest, venous accumulation of blood in the abdomen and liver, depression of sensibility of the irritable organs, manifestation of the greatest relaxation of the nerves, first convulsion, then paralysis of the muscles, extreme apathy; also thick fluid, oily blue-black blood, anxious, labored respiration, slow moaning breathing, tracheal rattling, laryngeal paralysis or sudden paralysis of the heart. It is here where Naja may be of great use. Homologous to Nicotine portion of the abdominal portion of the sympatheticus and ganglia of the base of the brain with the medulla oblongata. Nicotine uraemia is, therefore, distinguished next to its asphyxia, which is of double origin (cardiac paresis from weakened function of the vagus from the medulla oblongata, and paralysis of the blood-globules from carbonate of ammonia), especially by torpor of abdominal ganglia, or paralysis of some plexus of the sympatheticus, e.g. of the diaphragm, and we find, therefore, as the most prominent phenomena of Nicotine-uraemia, thirstlessness, absence of all reaction, indifference to everything even to death, cold forehead, absence of vomiting and of diarrhoea in spite of copious transudation in the abdominal tract, more or less total paralysis of the intestinal coats and of the muscular coats of the arteries, absence of all secretion from liver and kidney and death, far quicker than in any other form of uraemia. On another line it is under such and similar conditions that I cannot too strongly protest against abandoning our cholera remedies. Camphor, Secale Cornutum., Tartar Emetic–they have all an obstructing action on the urinary organs, and make by far better auxiliary remedies, than Cantharides, Terebinthina, etc. which remedies should only be used after the chief danger has been subdued; although it is more than likely that, should we have succeeded in accomplishing this task, then the function of the kidneys will manifest, itself, without any further medication. Again, remedies like Opium, Hyoscyamus, etc., may have their place when reaction is properly established, when urine has been passed, yet there is some cerebral congestion, with more or less pronounced febrile symptoms–a conditions chiefly concerning the cerebral blood-vessels. Often we find, especially in children, symptoms of stupor, even after urine has been passed. In such cases it may be owing to hydrocephaloid; the pupils are dilated. Helleb. Nig., Sulphur, Calcarea Phosph. (vide Korndoerfer’s Clinical Materia Medica) and perhaps Apocyn. Cannab. may then be called for; and so may Zinc or China, to be followed by Calcarea Phosph. if the first is insufficient or inactive. This might represent the general plan of treatment provided none of the other drugs just mentioned, are distinctly called for. Iodoform (see Burt’s Physiological Materia Medica) should not be forgotten in Hydrocephaloid. The indications for Sulph. and Helleb. are given in Korndoerfer’s Clinical Materia Medica. Cina is another remedy which deserves study in connexion with the above. In typhoid symptoms accompanied with tympanitis and absence of urine, we may, however, fairly think of Terebinthina.
In the torpor ensuing after the choleraic stage has passed, we should be careful to distinguish between a possible state of hydrocephalus and Hydrocephaloid. In the first there is serous effusion, in the second the symptoms are owing to cerebral anaemia. It is especially in children where we meet with such cases. Concerning the treatment of hydrocephalus, a number of remedies has been mentioned before. Hydrocephaloid begins with excessive restlessness and ends with torpor and exhaustion. This excessive restlessness may be owing, as far as I understand it, either to an unequal distribution of the blood that is still left in the patient–the cord being congested (and consequently irritated) at the cost of the circulations of blood in the cerebral region; or the restless twitchings and actual convulsions may be owing to a deficient inhibitory action on the part of the anaemic brain. The decision between the two possible causes is not easy. So much I may say that Cicuta Virosa should be administered where there is suspicion of spinal congestion, while Muscarine is an excellent remedy when the restlessness is owing to insufficient cerebral inhibition. Again if the case is diagnosed as hydrocephalus our attention should be directed to stop the effusion by such remedies as Calcarea Phosph., Helleb., Apis, etc. While in the case we have to deal with– hydrocephaloid–the application of such remedies would be a mere loss of time. We cannot give blood to the patient by administering a drug. Our Materia Medica has no such drug which may be transformed into flesh and blood. All we have to do is to remove such conditions which interfere with nutrition; to promote the voiding of the urine when the bladder is found to contain urine; and to spare the patient’s strength by administering such remedies which prevent the nervous waste manifested by a state of utter restlessness. If we succeed in all this, the cerebral anaemia will gradually disappear.
As a rule the discharge of urine on the part of a cholera patient is to be taken as a sign that the cholera process is at an end, that metabolism of the organism has set in in a normal manner. Amongst the many vagaries of cholera I had, however, occasion to observe, especially in the winter season of 1889-90, cases where the excretion of urine was, if anything, rather a foreboding of death. In fact one of my patients died immediately after passing water. They died all with unmistakable symptoms of uraemia. Dr. Kanai Lall Dcy, former Chemical Examiner to the Government of Bengal, analysed a few specimens of urine, passed by patients, who sooner or later died of uraemia, and compared it with the first urine of such other patients who survived the attack, the passage of urine having shown the first sign of improvement. He found that the specimens of urine of the former class were of a specific gravity, 1,000, without any salts or coloring matter; it was to all intents and purposes simple water, while the specimen of the other class showed to have a specific gravity of about 1,020, and contained the usual elements of urine with excess of oxalic acid and epithelial cells.
I have been particularly requested to give ample indications for the treatment of hiccough, a disorder of a most troublesome nature, and by no means insignificant, liable to occur with more or less severity and persistency, at the time when reaction is about to set in, or has already set in. My impression is that when practitioners do not succeed, they have to ascribe the failure to themselves. As a rule the patient is altogether forgotten in such cases, and the hiccough alone is treated. Why run after such remedies as Ignatia, Nux Vom., Cicuta or Belladonna, which have no relation whatever to choleraic patients? But when the patient, it might be said, is in a state of reaction, he is no more a cholera patient. Well, is not the physiological action of out cholera remedies followed by a reaction? Do you think that a man who has been poisoned by Veratrum, and has been actually brought thereby to a state of collapse–do you think that such a subject recovers without any transitory reaction? Just look at our materia Medica, please, and you will see there all the phenomena of a reaction clearly depicted under each drug’s pathogenesis. Why then run off the line in search after new therapeutic agents? Veratrum, Cuprum, Secale, Carbo Vegetabilis, Arsenic, Cuprum and Strychn,. Ars; (also Arsenicum Iodium when there is much wind;) Tabacum and its alkaloid nicotine and Hydrocyanic Acid, also Agaricus and its alkaloid Muscarine, they have all hiccough amongst their pathogenesis, and succeed far better–I speak from experience– than such far fetched drugs, that may have beneficial effects in hiccough occurring in common disorders of indigestion or spasms, but that have for all that not the slightest relation to the case before us. Hiccough may either be centric in its origin, in which case the seat of irritation is either at the base of the brain or in the cerebral portion of the spinal cord; or, secondly, the seat of the irritation may be somewhere along the course of the phrenic nerve, or at its peripheral extremity; or, thirdly, the irritation may be reflex. Besides, this hiccough has often been observed in protracted cases of anaemia; the irritation, in such cases, is supposed to be central, brought about either by insufficient nutrition (Cuprum, Veratr.) or by the retention of impurities in the blood owing to a defective tissue metamorphosis; such instance is met in the last stage of Bright’s disease where the blood is surcharged with urea. This will explain the frequent occurrence of hiccough in cholera. Two drugs particularly known to give rise to hiccough are : Tabacum and Alcohol. Amongst those who first try to smoke tobacco hiccough is a troublesome symptom. The drunken man is so well known to be afflicted by hiccough, that he is never caricatured without his companion. We should certainly first of all try in cases of hiccough a few drops of Rectified Spirit often repeated. Sulph. Acid prominently produces hiccough and should be remembered. Oxalic Acid should certainly find a place as a hiccough remedy in cholera collapse.
Similar remarks are applicable to the treatment of the reactionary fever. There was a time when a cholera patient was looked upon as three quarters saved when he had once reached the stage of reaction. Not so, since a few years; even in these matters the type of the disease has changed of late, at least in Bengal. In fact, people have learnt to dread the stage of reaction almost more than the stage of collapse. What lessons are we to learn from this, concerning our therapeutic proceedings? It appears to me, that we must begin to look upon these fevers, as they occur after the cold stage of cholera, as a part and parcel of the cholera attack itself, and arrange our treatment accordingly. Of all the drugs, Belladonna is the most misused on such occasions. Let us use Veratrum instead or, better yet, Euphorbium which acts similar to Veratrum on the digestive organ and, at the same time, similar to belladonna in regard to cerebral congestion. The late lamented Dr. Hering, who had felt years ago, the ill use Belladonna is put to by practitioners of our school, says : Both (Belladonna and Veratrum Album) are often indicated in typhoid fevers, it is true, in widely different cases, but sometimes the choice is difficult, particularly as Belladonna is equally applicable in apparently opposite states. Both have apathy, stupor, unconsciousness or great sensibility to noise and also to light; dislike to talk, except in delirium; (the latter sometimes is furious); great fearfulness; eyes dim and glazy, face pale or by turns red and hot, distorted features, sudden startings in sleep, grinding of teeth; both have much thirst, frequent drinking, but only little at a time; the mouth dry, saliva lessened; diarrhoea; involuntary discharge of the faeces and the urine; both have nymphomania and other uterine affections in common. With both the head is often turning hot, while the limbs are cold; both have an aversion to being covered, both indicated particularly in children and women, etc. Veratrum has a great similarity with Lycopodium in typhoid complaints of children; Belladonna with Rhus or Calcarea. Where there is so much similarity, I should say the decision should in most cases fall on the side of Veratrum, in post-choleraic fevers; especially as the signs of cerebral inflammation, so characteristic of Belladonna, are entirely absent in this class of fevers. In fact this characteristic absence of inflammation by itself, should suffice to determine out choice in favour of Veratrum; but we cling to routine and prescribe Belladonna.