In these cases there is, what was striking to me because it is usually so common, only a fairly moderate secretion of sweat.”
Since the heat production is almost constantly increased by salicylic acid, perhaps the last observation of deficient sweating explains the fever. Moreover it is note worthy, that besides the antipyresis by “canalization,” a stimulative action is also possible under certain conditions, in which an action of much occur in the sense of the simile rule.
The reduction of inflammatory manifestations in the joints according to all appearances is not a local phenomenon which lessens or prevents oedema through alteration of vessel permeability. The action seems to occur rather through a central reduction of the circulation and also to a certain extent independent of the mechanism of antipyresis. Artificially chemically induced oedema is neither prevented nor improved by sodium salicylate.
On the other side Starkenstein has depressed the chemosis of mustard oil in rabbits and the dionine chemosis in patients with salicylates (even if more slowly than by atophan) however without consideration of the influence of reduction of circulation and alteration of blood pressure.
The analgesic action in rheumatic fever finally may be ascribed partly to the lessening of inflammatory afflux into the joints, but this may also have a central origin, since the action has found numerous application in non-inflammatory pains. Whether the action occurs directly on the cerebral pain centers or via a detour over the vasomotor nerves, is still not known.
RESULTS OF SALICYLATE THERAPY —————————– If now the bacteriotropic action of salicylic acid in joint rheumatism is denied and a polysymptomatic effect recognized, then it is by no means determined whether the known action of clinically maximal doses on fever, swelling, and mobility of joints is curative, favorable in the sense of an accelerated recovery and avoidance of complications (as the cardiac affections), or a lessened incidence of fatality. These questions can be clinically-statistically investigated and further studied accordingly from the side of theoretic plausibility, which is based on experimental results.
The question of the avoidance or improvement of cardiac affections in joint rheumatism by salicylic acid in the usual doses is answered decidedly in the negative. An unfavorable influence of salicylic acid on the frequency and severity of heart affections is proposed by one series of observers, denied by another.
The possibility of cardiac damage in any case is not to be entirely dismissed. States of collapse with cyanosis and comatose dyspnoea are observed from large doses. In animals there is a transient increase from smaller doses, falling of the blood pressure and finally diastolic stanstill.
The influence of the duration of the disease is difficult to determine. If the fever was a definite point of departure then the question would certainly be decided in favor of the usual salicylate therapy. But it depends largely upon the subjective view of the physician when he considers a patient with joint rheumatism cured. According to Hanzlik, Scott and Gauchat 551 8 patient under salicylic acid had an average duration of disease (from 6-38 days), 9 days shorter than patients who received no salicylate. J.L. Miller 552 showed in a statistical study on 1907 cases with and 1600 cases without salicylates that the average duration of the hospitalization in patients with salicylic acid was the same as without it. He comes to the conclusion that treatment with salicylic acid in no way favorably influences the duration of disease and the tendency to recurrences and that a complete refractory situation against salicylates is frequent. Poynton and Paine, 553 R. Miller, 554 and Zadek 555 decide similarly that neither the involvement of other joints, nor recurrences nor heart complications are prevented by salicylate therapy and that reappearance is just as frequent in the treated as in the non-treated.
In another statistical by Hanzlik 556 18 Percent were not improved by sodium salicylate in large therapeutic doses or were incompletely improved, and that in the improved repetition of the salicylates was frequently necessary because of recurrence of the symptoms.
Swift, Miller and boots 557 sought to obtain an objective criterion for the influence of salicylates from the white cell counts. At times during the treatment with salicylic acid the white count fell to normal, with discontinuance of salicylates the number rose again, to 4,000 or more over the original state, a sign that the infection again existed. If one has in the leucocyte count a suitable criterion for a decision on the course of the disease with and without salicylic acid speaks against an increase in the defense of the organism in the fight against an increase in the usual doses of salicylic acid speaks against an unknown cause, much more for a weakening (entirely in contrast to the manner of action of non-specific irritant bodies which have been found curative in about 40 Percent of the cases according to American authors). In the sense of a decrease of the intrinsic possibility of defense through large doses of salicylates also speaks the experimental studies in animals. Swift 558 found in rabbits who had received streptococcus viridans (living and in vaccine form) and washed sheep erythrocytes, a reduction in the antibodies agglutinins, and hemolysin formation and the complement fixation under large doses of salicylates in contrast to control animals.
From animal experiments proceed even more significantly the results of experimentally produced arthritis in rabbits. Salicylic acid proves useless for the aviodance of arthritis from the injection of hemolytic streptococci. 559 In the arthritis from various types of streptococci, the animals die more frequently under salicylate treatment than the controls which had no salicylates. 560 Swift and Boots 561 obtained the same result with non-hemolytic streptococci. The animals which received salicylic acid before and during the infection died earlier than those without salicylic acid. It remains undetermined whether the view of the authors is correct, namely that the cause is a summation of the renal damage through the bacteria and salicylate.
Of interest was the finding on the severity of the joint inflammation. Approximately one half the joint inflammations (from streptococci of slight virulence) in the animals with salicylates were of a mild type, while the inflammation in the controls was severe. But nevertheless 36 Percent of the animals treated with salicylates died while only 8 Percent of the controls. The apparent local improvement also stood opposed to the unfavorable course of the general disease.
Accordingly the theory of etiotropy and increased intrinsic resistance by salicylic acid does not contain in its characteristic domain in the acute rheumatic fever, whereas one is confronted by the confirmed experience that in innumerable cases, salicylic acid can bring some of the cardinal symptoms of rheumatic fever to disappearance. The chief action of salicylic acid on the vasomotor and heat center and the central reduction of pain in general have a palliative value. Moreover a canalization especially through the sweat and kidneys in the sense of an alleviation of the healing endeavor is to be considered. But it is doubtful how far the organism is weakened in the active fight against the infectious excitor. These reflections hold for the great doses of salicylates (8-12 grams pro die). This does not exclude in any way that in single cases of rheumatic fever salicylic acid can be more than a palliative and that in single cases it may give permanent results. In the sense of a derived irritant therapy according to the symptoms, as homoeotherapy is, such results are to be expected when the effect picture of salic- ylic acid presents a similar picture. And this is actually the case. But the confirmation would first be brought when small doses (stimulant doses) yield a good result in these cases. This expectation must be realized still more when benzoic acid which is closely related to salicylic acid, is found often to be suitable in joint rheumatism in accordance with homoeopathic use. If an agent like benzoic acid, in provings on the healthy, produces many expressions in the human organism such as symptoms which are similar to those of joint rheumatism, small doses of it have been proven useful, so it is certainly not a palliative agent suppressing single symptoms, that is, it is directed not against the healing endeavors of the organism but conforms with them. With the provings of salicylic acid available up to the present this trend of action has not been sufficiently tested and even less investigated. That salicylic acid often produces sweats in the healthy and also high fever in those disposed, also occasionally springing pains in the joints with aggravation from movement and contact, moreover an urticaria related to that of rheumatism ( I recall here that the arthritis in joint rheumatism has been cons- idered as an allergic manifestation by Bauer 562 speaks for the possibility of a specificity in the homoeopathic sense. Between the extreme the specificity for the joint rheumatism (which can exist only in etiotropic action on the excitor) and the non-symptomatic symptom suppression, homoeopathy sees a specificity in the sense that the medicinal agent can be adapted to especially suitable single cases by comparison of the symptoms.
OTHER ACTIONS AND USES
The chief trend of salicylic acid on the nervous centers is also revealed in the well-known so-called untoward actions: pains in the head, vertigo, ear noises and difficulty in heating, nausea and vomiting.
In regard to the obviously vasomotor headaches, it is to be recalled that Wiechowski 563 found widening of the peripheral and contraction of the intracranial vessels in animals with sodium salicylate. Probably this is connected with the palliative action of salicylate preparations in headache.
Nausea and vomiting are centrally conditioned, because with the intravenous injection of sodium salicylate vomiting occurs, inde- ed, sooner than after an oral administration. 564
On the basis of animal investigations the ear symptoms have been traced to hyperemia and hemorrhage into the inner ear, according to the investigations of Haike, 565 however the alterations in the N. acousticus and Ganglion vestibulare and spirale are also to be recalled. However in spite of these findings an influx of blood with vascular over filling in the sensitive innerear is not excluded.566
The observations on the eyes also speak for a marked vasomotor influence, in which a series of subjective and objective salicylate symptoms have been observed. A narrowing of the retinal vessels has been reported. 567 Also in dogs after subcutaneous injection of large amounts of salicylate a decrease in visual capacity has been found, narrowing of the visual field and pallor of the optic nerve.
On the skin erythema, vesicular eruptions, and especially urticaria are often observed as untoward symptoms, more rarely a purpura. In sensitive people receiving aspirin a partial oedema may appear which however can be ascribed more to the acetyl component. Formerly salicylate solutions were used in itching eruptions, urticaria, eczema and pruritus. The external use of salicylic acid for the solution of cornified epithelium and for the suppression of foot sweat is generally known. From poisonous internal doses (13.3 grams of sod. sal.) one has seen besides stupefaction and muscle twitching also a suppression of the sweat secretion.568 On the other side the production of sweating by moderate doses is known.
Similarly animal experimentation has shown the increase of salivary and biliary secretion, on the contrary complete failure of these from larger doses. 569 In large doses salicylic acid (as well as benzoic acid) markedly increase the excretion of indican in the urine. 570 This is probably connected with a one sided in- fluence on the intestinal flora.
The usual mass use of salicyl preparations in fevers of all types chilling, grippe, rheumatism, pleuritis, pneumonia, sciatica and other forms of neuritis, headaches, migraine is found no better than in joint rheumatism but the pure symptomatic palliative effect is obvious. The limits and disadvantages of such treatment need not be discussed here nor misused by a badly informed public.
DRUG PICTURE OF ACIDUM SALICYLICUM
Our knowledge of the actions of salicylic acid is based for the most part on the so-called untoward effects. The provings on the healthy are insufficient. They are:
1. Lewi: Hirschel’s Ztschr. f. hom. Klin., Bd. 20, p. 106, 1875.
2. Chase: N.E.Medorrhinum Gaz., Bd. 12, p. 564.
3. Cushing: Trans. Mass. Hom. Soc., 1878/79.
4. North: Practitioner, Bd. 23, p. 184.
The chief action of salicylic acid proceeds on the nerve centers. Vertigo, ear noises, difficulty in heating, often accompanied by nausea, give the practically important indication in Meniere’s syndrome.
Generally there is a feeling of weakness, dullness of the head; headaches appear paroxysmally or remain constant, in the frontal region or over the entire head, tearing, pressive, throbbing or as a boring pain in the temples. The vertigo is rotatory with a tendency to fall to the let. Headache and vertigo are worse from motion. Uncertainty in the movements, leaning the body to one side, striking against objects, trembling of the hands occur. The difficulty in heating is accompanied by ear noises of all kinds. Also flickering, weak vision, transient blindness, squinting, mydriasis or miosis is observer in the eyes. Psychical disturbances go from poor memory to maniacal states with delirium, hallucinations and illusions.
Nausea and vomiting can appear even after proportionately small doses and may last for several days; the vomitus may be blood streaked. In severe salicylate poisoning it often amounts to hemorrhage; from the uterus (therefore in massive doses it has been used as an emmenagogue and abortifacient), from the nose, from the mouth, esophagus, stomach, intestine, and as hematuria. However no use has been made of all these symptoms homoeopathica- lly. The reports on inflammation of the throat and the use in diphtheria arises from the proving of Lewi 571 and can scarcely be associated with one dose of the 1 C trituration. Offensive eructations, distension in the stomach and intestine with colicky pains, offensive diarrhoea have led to the occasional use in dyspeptic flatulence. Here the increased excretion of indican from salicylic acid is to be remembered. The gastro-intestinal symptoms also have a great similarity with those of phenol.
The undoubted action in many rheumatoid inflammatory processes is given through the already mentioned pains in the joints, which leap from one place to another, through profuse sweats which relieve, but generally weaken and through the connection to the heat center; the aggravation from movement, contact, from cold and at night, the relief from the application of warmth, in particular heat, may assist to some extent in determining suitable cases. However these signs scarcely characteristic in themselves have been partly derived from patients. Involuntary twitching and trembling appear in the muscles. With regard to the biphasic action on the secretion of sweat and the frequent use against foot sweat is the report “results of suppressed footsweat” also to be noted for the rheumatic patient.
Vasomotor syndrome. Sensorium.
Modalities: (uncertain) Worse from contact, motion, cold, at night.
(Results of suppressed foot sweat.) Better from warm applications, dry heat.
DOSE —- In Meniere’s syndrome it has proven useful in many cases in the D 3 trituration.
Benzoic acid is a constituent of many plants and is obtained by distillation from the resin of types of styrax. In the urine of herbivorous animals, glycocoll (amino-acetic-acid, H2N. CH2. COOH) is bound with it to form hippuric acid (C6H5. CO. CH2. COOH) (There is a similar pairing for salicylic acid in the form of salicyluric acid.) Not all the benzoic acid is paired with glycocoll and excreted as hippuric acid, but the greatest part is in men. Glycocoll is apparently only gradually liberated. Thus it is possible that benzoic acid unfolds its special influence in “rheumatic” processes in the supportive tissue on this part of the protein metabolism.
Exactly as from salicylic acid the nitrogen excretion in the urine is increased by large doses of benzoic acid. In animals the urinary output 572 and the bile excretion 573 is increased. In the antiseptic action it behaves about the same as salicylic acid. Of the mixed bacteria of the faeces, the colon group are influenced more than the coccus forms by it. The indicanuria signifies an alteration of the bacterial flora, and has been demonstrated from benzoic acid as well as salicylic acid. 574
The transition from amounts of benzoic acid which are apparently born without symptoms to very severe poisoning has been found extremely variable in dogs. 575 This is probably connected with the amount of available glycocoll.
If the detoxifying glycocoll pairing is not sufficient then the toxic symptoms are noted particularly in the nervous centers, in animals investigations in the form of spasms, ataxia and finally paralysis. After washing out an ovarian cyst with more that 100 g. of sodium benzoate, a maniacal confusion has been seen. 576 1- 2.5 g of benzoic acid or sodium benzoate in 4-5 daily periods in 12 healthy persons produced nausea, vomiting, headache feeling of sweating, burning in the esophagus, often also a sensation of hunger and digestive disturbances. 577 Nausea and vomiting, the latter revealing blood, is centrally conditioned as with salicylic acid because both are observed after parenteral use.
Inhalations of benzoic acid are still employed at times for the improvement of expectoration in bronchitis, and in the ’70s it was much used in tuberculosis on the recommendation of Rokitanski
Stockmann 578 found that benzoic acid was effective in rheumatism but somewhat less than salicylic acid. The same untoward effects are reported for benzoic acid as for salicylic acid.
ACIDUM BENZOICUM DRUG PICTURE
The provings are compiled in:
Hering: Amerikanische Arzneiprufngen, vol. I, p. 703, 1857.
RHEUMATIC-ARTHRITIC CHIEF TREND
In homoeopathy benzoic acid is considered as a remedy for the rheumatic-uric acid diathesis.
As the chief symptom it has the sharp odor of the urine, like the urine of horses, as it states; offensive, sharp, penetrating, intensely “urinous” odor and indeed immediately on voiding. This is moreover an indication of an abnormal protein split product, which hippuric acid is to be considered in man, when it appears in large amounts. The urine is concentrated, dark brown or deep red. The desire for frequent voiding is present.
In patients with the uric acid diathesis, with the tendency to true gout as well as to rheumatism, the amount and salt content
of the urine is subjected to great variations. At the times of small output and light urine with relatively low specific gravity the patient has the most bodily and in particular rheumatic complaints. If then an outpouring of salts follows, particulary of uric acid, with an increased amount of urine, an amelioration of all symptoms occurs. The relation between the excretion and the complaints is characteristic for benzoic acid, when the sharp odor of the urine is present.
In children the uric acid diathesis may reveal itself early in the penetrating “urinous” odor and in these cases acidum benzoic- um can also come under consideration for enuresis nocturna.
In the provings a series of symptoms in the joints and extremiti- es have been observed: tearing and sticking pains and occasionally swelling (so that the ring would be too narrow for the finger), particularly severe pain in the Achilles tendon near the heel, occasionally the feeling of dryness and clicking in the knee joint. The wandering of the pains from above below and from right to left is a further characteristic; but the most important is always the character of the urine.
Moreover for the utility in acute rheumatism speaks a number of mild febrile symptoms in the proving protocols: sweat, internal heat (after preceding external coldness), with marked palpitation (with now fast, now non-accelerated, hard, beating pulse), pulsation in the arteries of the temples (sounds as whizzing in the ears), pain and sensation of weakness in the cardiac region. Obviously benzoic acid is not a remedy for rheumatism in general but only for rare cases, which one can recognize best through the peculiar acrid odor of the urine. Moreover it seems that in the cases suitable for benzoic acid the sweats do not relieve. Use of wine is said to aggravate, likewise movement and cold.
More frequently than in acute rheumatism, benzoic acid is employed in subacute and chronic rheumatism and indeed in arthritis deformans. In addition to the condition of the urine there is also the psychic state, the sleep and the headache. Periods of specially deep, stuporous sleep alternate with sleep disturbed by excitement and a tendency to dwell upon unpleasant things.
Moreover the frequent omission of words in writing is striking. Dullness of the head, and dull headache in all parts of the head, especially in the occiput, occur with lassitude, malaise and loss of appetite, and in conjunction with rheumatic pains and deficient urinary output, after chilling and coming over night with change in the weather, recur periodically, are worse at rest and often accompanied by gastric pain, nausea, regurgitation, and cold hands. It involves a headache on the soil of arthritism. Vertigo with a tendency to fall to one side is also observed, on the other hand ear noises seem to be rarer than in salicylic acid. However benzoic acid is also recommended in Meniere’s syndrome.
Likewise a series of inflammatory states of the tongue, throat, tonsils, or in the stomach are associated with rheumatic manifestations. They are said to appear in place of suddenly diminishing joint pains, with lessening of the urine, which then becomes high colored and of strong smell. The manifestations are: soreness of the tongue, acute inflammation of the tonsils and the throat (burning and scratching pains in the throat have also been observed after the inhalation of 2-5 Percent sodium benzoate solution); loss of appetite, white slimy coated tongue, eructation and gastric pressure with bitter taste, nausea and bitter or salty vomiting from all foods. Watery diarrhoea, especially in children when it is accompanied by the urinary symptoms discussed. The stools are usually foul and white as soap water, at times putrid and bloody.