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.
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.
