If I were asked: Which are the drugs that may be expected to act similar to Camphor in the first stage of spasmodic cholera? My answer would be: Hydrocyanic Acid, and next to it: Arsenic. I shall not trouble you, by reading to you a number of cases of poisoning by the acid named. You will find them recorded in the 4th and 10th volume of Allen’s Encyclopaedia. Sudden falling down with loss of consciousness owing to excitation of the cerebral sympathetic, with its consequent sudden withdrawal or shutting out of arterial blood from the brain, is, in all cases of poisoning, worthy of the name, the first effect of the drug’s action; then follow epileptic convulsions, spasmodic breathing and tetanic cramps; on the whole a second edition of what you have learnt now to recognise as Camphor poisoning or spasmodic cholera. As the acid is by far more virulent than Camphor (one grain being sufficient to kill an adult, while 160 grains of Camphor, would set up alarming symptoms for a time, but would allow the patient completely to recover) I shall give you one of Hydrocyanic Acid poisoning, which ended, as most such cases do, fatally. We shall have then the advantage to study the post mortem changes effected by the drug-changes we can hardly ascertain in the case of Camphor poisoning, as there is hardly a fatal case yet known.
A girl, aged 22 years, swallowed by mistake a dose of Prussic Acid, equivalent of a little less than a grain of pure poison. At the time when this was taken she was sitting in a chair; but she instantly jumped up, ran for a short distance holding up her arms and gasping, as it were, for breath; she then fell, became insensible and was violently convulsed, the muscles of her face undergoing great distortion, her limbs becoming spasmodically extended and her head drawn down upon her shoulders. In this state she was removed to her bed and was seen directly afterwards by Dr. Watson, who found her lying on her back, with the body drawn a little forward; the limbs fixed and extended in tetanic spasm: the whole face swollen, turgid and almost purple from congestion; the jaws clenched; the mouth covered with foam; the eyes half closed, but prominent and glistening, with their pupils widely dilated, and quite insensible to the stimulus of light. She was breathing slowly, with deep prolonged inspirations, and uttering a low, moaning noise. The pulse at her wrists could not be felt, although the heart still continued to beat with a feeble fluttering effort…. The breathing became slower and deep prolonged inspirations, and uttering a low, moaning noise. The pulse at her wrists could not be felt, although the heart still continued to beat with a feeble fluttering effort… The breathing became slower and slower, the limbs at this time remaining fixed and immovable; and she died in from fifteen to twenty minutes after the ingestion of the poison. The post-mortem appearance in this case was as usual in cases of poisoning by Hydrocyanic Acid. The cerebral vessels, both upon the surface and in the substance of the brain were full of black, fluid blood; the lungs highly congested, but free tubercle or other disease; and the cavities of the heart full of black, uncoagulated blood.
Spasmodic respiration is noted by all observers of acute poisoning. Boehm pointed out that it is to expiratory stage that this character especially belongs. According to Dr. Wood, the chronic effects of the vapor are: difficult respiration, constriction of throat, and feeling of suffocation.
If you remember the description of Niemayer, as quoted in the first of these lectures, of the appearance of the blood after death of cholera victims, then you will find in the haematic effects of Hydroc. Acid an additional similarity to spasmodic resemblance between the two.
Dr. Russell, I believe, was the first who applied it in cholera. Hydrocyanic Acid, he says, we have seen give at least temporary relief in a few cases, where there was great prostration and oppression of the chest. One poor woman, a sober respectable person, who had been ill for twelve hours when we saw her, and complained much of excessive uneasiness at the heart exclaimed after a few doses of Hydrocyanic Acid, `God be thanked, my breast is getting benefit’ and for some time there was decided improvement both in her sensations and appearance. On the whole, however, we believe that the number of cases in which it is indicated, will not be found large; perhaps the particular period suited for its administration is very short.
I need not tell you that Hydrocyanic Acid has never ceased from the time of Dr. Russell, that is from the year 1848, to be one of our stock remedies in the state of cholera collapse.
Some years ago I took occasion to address a letter on the subject to one of the Calcutta daily papers; and although the letter dates as far back as 1876, I believe it may still be of sufficient interest to you. It runs as follows:
(TO THE EDITOR OF `THE ENGLISHMAN.)
SIR,-The last issue of the Englishman’s Saturday Evening Journal contains an article headed The Month: Science and Arts, in which it is stated that Surgeon-Major A.R. Hall, of the Army Medical Department, had lately introduced a new method of treating cholera patients in the cold stage, or collapse. Surgeon-Major Hall had himself an attack of cholera, during which he observed, while his skin was blue and cold, and when he could not feel the pulse at his wrist, that his heart was beating more forcibly than usual. He, therefore, concluded that the want of pulse at the wrist could not depend upon want of the power in the heart; and after a reference to the works of the distinguished physiologist Dr. Brown-Sequard, he came to the conclusion that the heart and all the arteries in the body are in a state of spasmodic contraction. The muscular walls of the heart, therefore, work violently, and squeeze the cavities, so that the whole organ is smaller than it ought to be; but it cannot dilate as usual, and so cannot receive much blood to pump to the wrist. Surgeon-Major Hall believes, consequently, that the nervous system wants soothing, instead of stimulating, and recommends sedatives in the state of collapse, in the place of stimulants, hitherto used, and concerning which experience has shown that they do more harm than good. This method of treatment was applied in twenty cases where the patients were either in collapse, or approaching it, and eighteen of these recovered. They were natives of Bengal. Surgeon-Major Hall recommends in severe cases, among Europeans, the employment of Prussic Acid, Calabar Bean, and other true sedatives. The article closes with the following words: It is to be hoped that this sedative treatment may have an extended trial, and that before long, we may have further favourable reports concerning it.
Now, is it not strange that writers on medical subjects should ignore the existence of a school of medicine which has, since 1932, the first time cholera made its appearance in Europe, all along protested against the use of stimulants, and insisted, moreover, upon treating cholera patients with medicines which act anti-spasmodically? I need hardly say that it is the homoeopathic school of medicine to which allusion is made here. The sedative treatment of cholera has had an extended trial, indeed, and the reports concerning it have been favourable to such an extent that cholera may fairly be considered as the pioneer of homoeopathy all over the world. Yet we are now recommended to hope and to try!
Surgeon-Major Hall recommends, amongst other true sedatives, the employment of Chloral Hydrate, Prussic Acid, Calabar Bean, and Bromide of Potassium. Out of these four drugs, Prussic Acid is the most powerful, and it is this drug which amongst others, homoeopathy have now tried for the last forty years.
This is not the place to discuss the modus operandi of sedatives in cholera. Surgeon-Major Hall, inspite of his large and varied experience of cholera at the sick-bed, during a sojourn of 12 years in Bengal, had not come to learn the true nature of the action of cholera poison till he felt its effects upon himself. It remains now for him, and for his school of medicine, to enlighten themselves in a similar way about the true nature of the action of what they call sedatives! Nothing short of a most careful and minute proving of those so-called sedatives on themselves, when in a state of health, can elicit the true action of these drugs. This is the way in which homoeopaths have gone to work; and, when our learned brethren of the allopathic school will have done the same, then, and not before, will it be time to discuss with them the modus operandi of drugs as therapeutic agents.
July 30, 1876.
You see here, gentlemen, the way in which our noble friends of the allopathic school appropriate to themselves our valuable remedies under a false name and a false pretence. To them, Hydrocyanic Acid is a sedative, because they know it to be capable of checking spasms; as to its toxicological action on the healthy, they do not know, or do not care to know. To them, Chloral Hydrate, Prussic Acid, Calabar Bean and Bromide of Potassium, are, each and all of them, neither more or less than sedatives. The wonder only is, why Surgeon Major Hall did not derive as much benefit from Chloral Hydrate, a sedative par excellence, and a true and undoubted physiological sedative besides.
I hear you ask: But what has all this to do with the first stage of spasmodic cholera? Dr. Russell made use of the drug at the stage of collapse, and so has surgeon-Major Hall. My answer is: The benefit to be derived from the drug in the far advanced stages of cholera, should not deter us from using it, wherever indicated, in any of the previous stages of the disease; and I do not hesitate to say, that in what Hahnemann called the first stage of the spasmodic variety of cholera, Hydrocyanic Acid is just as eminently homoeopathic as Camphor. Then there are cases where the spasmodic contraction of the heart causes pain in the praecordial region at the very onset of cholera, or in the measure as the disease progresses. It is a short of Angina Pectoris. Here I have seen Hydrocyanic Acid and its alkali Cyanide of Potassium giving speedy relief, while Cuprum Met and Arsenicum failed. The choleraic discharges went on unchecked, and required ulterior medication but the distressing pain was relieved.
As a point of further similarity between the drug`s action to cholera, I may quote here, from Dr. Hughes’ `Pharmacodynamics’ the following passage: There is good evidence of the action of Hydrocyanic Acid on the solar plexus. Sir B. Brodic applied one drop of the essential oil of bitter almonds to his tongue. He immediately felt a remarkable and unpleasant sensation at the epigastrium, with such weakness in the limbs and loss of power in the muscles, that he thought he should have fallen. And Dr. Hughes continues: I have frequently removed by it the distressing feeling known as sinking of the stomach, when this has been unconnected with the climacteric age. And further on: The curative power of Hydrocyanic Acid in pain at the stomach and vomiting must also, I think, be traced to its homoeopathicity thereto. `An overdose,’ writes the late Dr. Elliotston, `will in every person occasion nausea, vomiting, and pain and tightness at the praecordia.
Even applied externally, it has caused nausea, vomiting, vertigo and syncope.
When I say that, theoretically speaking, Hydrocyanic Acid should be eminently useful in the first stage of the spasmodic variety of cholera, it is hardly needful for me to remind you, that I include within the spasmodic variety of cholera, not only cases characterized from the beginning by spasms of the voluntary muscles, but also such as are marked from the outset by arterial spasms. This would greatly the drug`s usefulness, in fact would place it on an equal footing with Camphor.
I can offer no clinical experience in support of what I have stated, as far as my own experience is concerned. In fact, it was only while preparing these lectures that it dawned upon my mind that Hydrocyanic Acid is a close similar to Camphor, and should, therefore, be as useful at the onset of certain cholera varieties as Camphor itself has proved to be. Evidence can, however, be brought to bear on the subject from other quarters. Pereira looks upon the acid as a sort of specific remedy in gastrodynia. He reports a case of a lady who suffered for months and was permanently relieved, as by charm, and adds: It can hardly be imagined that irritation of the stomach can be rapidly removed by a substance which is itself an irritant. He further relates the case of a gentleman who, after an attack of ague, suffered for several months from excruciating pain in the bowels commencing daily about two o’clock and only ceasing at night; the patient was advised to take Hydrocyanic Acid; the first dose arrested the pain and there was no relapse.
All this goes to show, that in many a case, the drug just mentioned has even a larger sphere of therapeutic action in the spasmodic variety of cholera than Camphor. But Pereira goes even farther; he actually commends this acid in English cholera and says that he has often seen it cure severe forms of this disease, after Opium had failed. Pereira’s statement seems to find corroboration in the fact, that Chlorodyne-a secret preparation, known to contain Hydrocyanic Acid and Opium as its chief ingredients,-has no doubt helped to check the premonitory symptoms of cholera in a large number of cases. The preparation is almost everywhere in India to be found in plantations, in out- of-the-way-factories, etc. and I have heard it spoken to with the greatest praise. Of course, it is the Opium which for the greatest part does what good has been derived from it; the Opium which has a great and prompt effect in checking the progress of the disease, when taken at the very commencement, and which is almost sure to kill where it does not cure; nevertheless the fact that we see here Opium combined with the acid, goes to show that in the experience of the concoctor of the preparation, the addition of the acid must have resulted in a larger number of relief, than where the Opium alone has been used. Chlorodyne may then be looked upon as a partial proof of Pereira’s ascertion to the effect, that Hydrocyanic Acid has proved itself to be serviceable in English cholera where Opium had failed. Let me here mention in passing that there is a place in the homoeopathic treatment of cholera for Opium whenever we can with good reason trace the attack of cholera during an epidemic to fear of catching the infection, or to a general panic, or in cases where the patient gets so frightened at the very onset of a diarrhoea or cholera attack, that the fright prostrates him more than the disease. Opium at the beginning or as an intercurrent remedy will be of great service, it might even be indispensable. Aconite should also be thought of under such conditions. The choice between the two remedies should be made according to the symptoms. Another remedy worth mentioning here is Asarum Europ. It is drug corresponding to a nervous constitution. In such patients the hyperaesthesia may be so great that a second impression of the same magnitude as that received first, will have no effect. Coming back to Hydrocyanic Acid we find Dr. Hempel in his `Materia Medica and Therapeutics’ says: Our provings do not point to Hydrocyanic Acid as a remedy for cholera. This agent may cause vomiting and cramping pain in the bowels, but, in the case of Joerg’s provers, this pain was not associated with any urging to stool. On the contrary the tendency of the drug seems to be to limit the alvine secretions. If diarrhoea does occur as one of the effects of this agent, it is most probably in consequence of some peculiar idiosyncrasy in the patient’s constitution. In Pereira’s case the acid was probably used upon the principle of palliative antagonism.
After what you know about the drift of my argument on the subject, it is hardly necessary to tell you why I cannot agree with the late Dr. Hempel. He had evidently had no opportunity of seeing cases belonging to the spasmodic variety of cholera; he, therefore, rightly pronounced Camphor to be of no use in cholera, even in its first stage; and with the same reason he extended his judgment over Hydrocyanic Acid. We have, however, good reason to believe that the drug will prove, when indicated, as useful as, and perhaps even more than, Camphor. I believe, moreover, that it is owing to a certain routine, into which we have allowed ourselves to fall in matters concerning the homoeopathic treatment of cholera, that we have not yet tried the acid mentioned, at the premonitory stage of spasmodic cholera. It appears as if Hahnemann’s instructions had actually the effect of blocking the way to all useful suggestions concerning the premonitory stage of cholera. He had recommended Camphor, and Camphor is to be exclusively administered in that stage. Even if it were true, as Hahnemann asserted, that, provided Camphor be timely administered, not one amongst hundred would die; even then there would be room for Hydrocyanic Acid to save that most unfortunate hundred and first. But subsequent experience has but too clearly shown, that Hahnemann was too sanguine on the subject. We have yet to learn the existence of a drug that would invariably prove useful in all cases of a certain stage of a certain disease, be that stage even the premonitory stage. In most cases a certain degree of similarity between drug action and disease is sufficient for all therapeutic purposes. But there are cases, or let us say patients, where the usual amount of similarity is not sufficient to satisfy the therapeutic rule of similia similibus curantur; another drug may just contain in its pharmacodynamics all that is wanted to complete the analogy. And so I have no doubt that of the cases unaffected by Camphor, there will be some that would be beneficially affected by Hydrocyanic Acid. As already said before, I am unable to give you any clinical indications which could guide you in your choice between the one drug and the other; the similarity in all essentials between them seems to me to be perfect, and it would not be fair on my part to fix on some minor points of symptomatology, just to establish what has been called a distinction without a difference. I have thrown out some hints in this respect, in the course of this lecture; the rest must be left to future clinical observation.
It has been observed, and rightly observed, that the action of Hydrocyanic Acid is too evanescent and temporary in its character. I have myself often seen a flickering pulse of a cholera patient in the state of collapse gaining strength and apparent stability in a comparatively short time, say two or three minutes, from the administration of the drug; but the improvement lasts almost no longer than the time required to set it up. The dose would then be repeated, or even increased; there would again be some improvement for two or three minutes; then the medicine would gradually lose its effect altogether. I am happy to say, since I have substituted the Cyanide of Potassium to the acid, I have met with far better results in this respect. Many a case, that to all appearance gradually slipped out of my reach under the administration of the acid, was brought back to permanent improvement under the more steady influence of the Cyanide of Potassium. I carry with me the second and third decimal, and the third centesimal trituration, and begin as a rule treatment with a grain or two of the third decimal. Should you ever have the opportunity of trying Hydrocyanic Acid in the premonitory stage of spasmodic cholera, I would strongly advise you not to rest, in the case of failure, till you have substituted the Cyanide in the place of the Acid.
The next remedy I have to speak of in connexion with the spasmodic variety of cholera is, the second analogue to Camphor, or what I consider as such, Arsenicum Album. The similarity between the toxic effects of this drug and cholera is so well- known, that in many places of this country where criminal poisoning frequently occurs, the police authorities have been induced to issue instructions to their subordinates, drawing their attention to the great similarity of Arsenic poisoning to cholera, and instructing them at the same time how to differentiate between the two. The character of the evacuations is pointed out as one of the essential points of difference : in cholera they are colourless, odourless, rice-water like; in Arsenical poisoning, there is blood present in the stools, whether they are faecal or liquid; again the stools are greenish or blackish, and more or less fetid. In the later stages of Arsenical poisoning the characteristic rice-water stools of cholera may be present (A Text Book of Medical Jurisprudence for India by I. B. Lyon, F.C.S., Calcutta and London 1889, p. 144), and in the case they are liquid, they are sure to be colored, greenish or blackish, and, in some cases fetid. When the subject can only be seen at a stage of collapse, a stage where, even when due to cholera, vomiting and purging are as often absent together, then a distinction is almost impossible, and almost nothing else remains, in the case of a fatal issue, than to have recourse to the chemical examiner. There is yet another distinction between Arsenic poisoning and cholera, a distinction referring, like the previous one, to the stage preceding collapse; namely, that in Arsenic poisoning there is often febrile excitement at the beginning, while in cholera it is, as we know, all but the reverse. This distinction, however, does not hold good in all cases; for there are cases of Arsenic poisoning, which begin with difficult respiration, coldness all over and spasms-in short with all the symptoms peculiar to the first stage of spasmodic cholera. This is not an invariable effect of Arsenic; and its homoeopathicity to the first stage of spasmodic cholera cannot, therefore, compare with the homoeopathicity of Camphor of Hydrocyanic Acid to the same stage and variety. I should say, the spasmodic effects of the two drugs just mentioned are absolute; while those of Arsenic are, what Dr. Drysdale has called, contingent, that is to say drug-effects which, in order to be produced, would require a subject of special susceptibility.