In drawing a line between the spasmodic and non-spasmodic variety of cholera, with regard to the homoeopathic applicability of Camphor, I feel I must remind you again of what I understand by the spasmodic variety of cholera. To all appearance it would convey the meaning of a variety of cholera attended with spasms.But then we have seen that the non-spasmodic variety is by no means free from spasms, the same being present, and almost as severe in the latter, as in the first variety. What constitutes then a certain class of cholera cases as pertaining to the spasmodic variety is the fact, that the disease is ushered in by spasms, while in the non-spasmodic variety it is relaxation of the bowels which takes the lead, leading later on to all the disturbances peculiar to the disease, spasms included. Now there are spasms and spasms; arterial spasms and muscular spasms. It is the latter which, to the uninitiated, make themselves most conspicuous; it is the former however-the arterial spasms-which carry most danger with themselves. Do not therefore run away with the idea, that you deal with a non-spasmodic variety of cholera- that consequently to administer Camphor would be a mere waste of time-because your patient happens not to have a fit of tonic or clonic spasm at the onset. There may be nothing of the kind, and yet you may have a genuine case of spasmodic cholera before you. The voluntary muscles may not be spasmodically affected, but the muscular coat of the arteries may nevertheless be so, and this alone is quite sufficient to stamp the case of a spasmodic type. It would be a case of cholera marked by chill and depression-a case just as homoeopathic to Camphor, as one marked by chill and depression, plus spasms. The case previously mentioned of Dr, Russell’s little girl, who became suddenly and under his very eyes, cold, livid and shriveled, is, pathologically speaking just as much a specimen of spasmodic cholera, as Dr. Quin’s own case was, and as many others are, beginning with tonic muscular spasms; although symptomatically they widely differ from each other. Symptomatically they are even more than different from each other; they are opposite to each other; the one being marked by general depression, the other by a general morbid excitement of the voluntary muscular system. Yet, pathologically, they start from the same basis; it is only a difference of more or less of the same morbid state.
Whenever, therefore, during a cholera epidemic, a man is suddenly seized with difficulty of breathing, coldness all over with lividity of the face or of other parts of the body, with depression of strength, etc., we may be almost sure we have a case of spasmodic cholera before us; it is the spasmodic contraction of the pulmonary arteries in particular, and of the arterial system in general which is at the root of all the evil. Should we, moreover, be called to such a case, after vomiting and purging has actually set in, we can still hardly do better than Hahnemann advised us to do in his typical cases of cholera: We shall still try Camphor for a time, in the hope of that with the subsidence of arterial spasms, the choleraic evacuations will subside by themselves.
Wherever we find a certain pathological disorder of a definite character manifesting itself in two or more types, there we may be sure to meet with a number of intermediate forms of pathological, or symptomatological varieties, concerning which a strict classification would be no easy task. Something similar occurs with regard to cholera and the various modes of its incipient manifestation. Between such typical cases, well marked by spasms of some sort-muscular or arterial- and such other cases decided originating in a disordered and relaxed state of the bowels; in other words between the two well defined types of spasmodic and non-spasmodic cholera, there is a sort of intermediate type, not so easily definable as to its nature and origin. A man may have had diarrhoea for a few days, and the diarrhoea may have gradually or suddenly assumed the character of choleraic evacuations, and yet he may be, to all intents and purposes, at least to all intents and purposes as far as therapeutics are concerned, looked upon the treated as one affected with spasmodic cholera. The very premonitory diarrhoea of his may be the effect of an exposure, or to some other cause of general vascular derangement. Exposure to cold means, as to its effect on the human body, contraction of the arterioles and consequent stagnation of blood in one part of the body often leads to congestion in the portal system, and ultimately to loose bowels, is not merely a theoretical possibility, but an actual reality, repeating itself but too often, even under ordinary conditions of life, and so much the more under the influence of epidemic or endemic cholera. Under ordinary circumstances such diarrhoeas might get well by themselves, and do get well by themselves. Under the observation of the usual hygienic rules, reaction takes place, the flow of blood through the capillaries from having been stagnant becomes free and easy, the arterioles dilate and relieve the congestion in the abdominal viscera, and the diarrhoea ceases by itself. Under the influence of epidemic or endemic cholera spontaneous reaction is by far not so frequent; the diarrhoea is, moreover, actually apt to run on unchecked for days, inspite of all hygienic rules, till it gradually or suddenly assumes the choleraic character. But gradually or suddenly as the case may assume the character of cholera, it is evident that we have here nevertheless to do with a genuine case of spasmodic cholera. What determines the spasmodic character of cholera is not the suddenness of the attack, not is it the cramps of extremities; it is the fact that spasms of some kind have originated, and are, as far as can be judged, still keeping up the whole train of the choleraic disorder; and that is just what may take place in the class of cases before us.
I need not tell you moreover, that such cases are by no means rare; in some seasons or epidemics, they are the rule, while in others the premonitory diarrhoea is as a rule idiopathic, and decidedly of the non-spasmodic variety. To distinguish between one and the other is not always an easy matter; the history of the case may give us some indication; the state of the patient may afford us some further clue; and a certain practical acquaintance with the prevailing type of the disease, with the general state of health of the patient before us, with his habits and predispositions, may and will in most cases supply the rest of the information required on the subject.
As to the history of the case, we shall have to ascertain if the premonitory diarrhoea has set in consequent upon some irregularity in diet, or in connexion with some exposure to cold, with or without some signs of catarrh. In the latter alternative, patients may have felt chilly all along and uncomfortable, he may have been even troubled more by the chilliness than by the diarrhoea-all this would be so much the clearer an indication that it is the spasmodic variety of cholera we have to deal with, and that we should not exhibit any other remedy, should we even be called after vomiting and purging had set in, before having given Camphor or any of the analogues of Camphor, to be mentioned hereafter, a reasonable trial.
Concerning the state of the patient at the time when we are called upon to decide the special nature of his disorder, we may say: Whenever cyanosis and objective coldness of the body sets in at the commencement of the disease, it may be considered almost a sure sign that we have before us a case of cholera attended with arterial spasms. When the choleraic are idiopathic, cyanosis and objectives coldness increase with the frequency of the evacuations, and unless the same be very profuse from the very beginning, it takes a few hours, as a rule, before anything like cyanosis and sensation of coldness to the touch are prominently established. Their comparatively early manifestation shows that the venosity of the blood to which they are due, is not a consequence of the vitiated condition of the blood, but of the spasmodic obstruction in the pulmonary arteries. In such cases the dyspnoea will also be found greater at the very beginning than it would be the case, whenever the choleraic evacuations are at the root of the disorder. You will also find the thermometer in keeping with the general state of venosity, and consequently lower than in the non-spasmodic variety of the disease. In short, state of depression, coldness, dyspnoea and cyanosis, out of proportion to the choleraic evacuations just set in, denotes the origin of arterial spasms. The pulse will be found to be in a state of irritation, its sounds more or less accentuated; while in the non-spasmodic variety the pulse is soft and more or less compressible from the beginning, and the impulse of the heart is weakened. Corresponding with this state of things we find such patients listless, apathetic, indifferent towards all their surrounds; while the choleraic patient of the spasmodic variety is restless, full of anxiety-not so much anxious perhaps about his condition, as about the want of air he cannot help feeling.
