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.
