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.
