Part 136

Nor does the prevalence of a greater number of cases necessarily imply a heavier mortality. For Bianchi reports of Rome that cases of dysentery constituted but 2.28 per cent. of all the admissions into the Ospedale di San Spirito in 1873, while in 1874 the percentage increased to 3.68; yet the mortality of 1873 was 17.02 per cent., while that of 1874 was but 9.09 per cent.

Complications on the part of the nervous system, the status typhosus, pyæmia, and great prostration, necessarily render the prognosis grave, yet even these cases are not necessarily fatal. Thus, Jules Aron reports from the epidemic at Joigny (1876) a case of recovery after complete paralysis of the sphincter ani. The recognition and discharge of an hepatic abscess relieves the patient from the dangers of this complication. Peritonitis alarmingly aggravates the prognosis, and perforation is almost of necessity fatal.

PROPHYLAXIS.--The improved sanitation of modern times has already diminished the frequency and mitigated the severity of epidemics of dysentery; and this fact, which is only an accidental observation as it were, gives the clue to the means of its further prevention.

The selection of proper sites for camping-grounds, barracks, and hospitals, the prevention of overcrowding in tenement-houses, ships, and jails, the regulation of sewage, the care for the food and drink, the observation of the strictest cleanliness by authoritative control,--all these are general measures which suggest themselves in the prophylaxis of this or any disease.

In the management of individual cases the first precaution is to prevent the dissemination of the disease. Whether it be really contagious or not, every case should be managed, as Bamberger suggests, as though it were contagious; and this protection of others secures for the individual patient the most favorable hygiene.

The bedding must be frequently changed; the windows kept open to secure free ventilation, which, in the light of existing knowledge, is the only true disinfectant; and all the furniture of the sick-room, especially including the receptacles for the discharges, must be kept perfectly clean. For this purpose the best purifier is very hot water. The temperature of the sick-chamber, if it be subject to regulation, should never be allowed to sink below or rise above 65-70° F.

The drinking-water should be secured, during an epidemic, from the purest possible source, and if good drinking-water cannot be had, what there is should be thoroughly boiled.

The discharges should properly be mixed with sawdust or some combustible substance and burned, or if this be impracticable should be buried in the soil a few feet below the surface, and not emptied into water-closets or privy-vaults used by others.

Such articles of food should be abjured as have a tendency to produce intestinal catarrh. So unripe fruits, vegetables which readily undergo fermentation--in short, all indigestible substances--should stand under ban. But no prohibition should be put upon ripe fruits or simple nutritious food of any kind.

Lastly, individuals should protect themselves from catching cold. The {809} researches of Pasteur have disclosed the fact that certain germs of disease will grow and multiply in the body of an animal whose temperature is reduced, when they would not increase without it.

TREATMENT.--The first requisite in the treatment of an individual case is perfect rest. Patients with even the lighter forms of catarrhal dysentery should observe the recumbent posture, and cases of more serious illness should be put to bed. Rest in bed, an exclusive diet of milk--which should always have been boiled--and the time of a few days is sufficient treatment for the mildest cases. Where there is objection to milk, meat-soups, with or without farinaceous matters, rice, barley, etc., may take its place.

A case which is somewhat more severe will require perhaps a light saline laxative--a Seidlitz powder, a dose of Rochelle salts or Epsom salts in broken doses--or a tablespoonful of castor oil or five to ten grains of calomel, to effect a cure. For the relief of the pain of the lighter cases nothing is equal to tincture of opium, of which five to ten drops every three or four hours in a tablespoonful of camphor-water acidulated with a few drops of nitric acid will generally suffice; or Dover's powder in broken doses, one to three grains, with five to fifteen grains of bismuth or soda, or both, is a good substitute for a change.

The successful treatment of dysentery in any form depends upon a recognition of the fact that the disease is local as to its seat, and is probably specific as to its cause. The anodynes relieve the effects, but the laxatives remove the cause. Consequently, the most rational treatment of the severer cases is the irrigation of the large intestine and the thorough flushing out of its contents. The use of clysters in the treatment of dysentery dates from the most ancient times, with the object, however, rather of medicating than washing out the bowel. O'Beirne (1834) and Hare (1849) were the authors of the irrigation treatment, which they executed by means of a long tube introduced into and beyond the sigmoid flexure. Since Hegar has recently shown how the whole tract of the large intestine can be thoroughly inundated and flushed with a common funnel and rectal tube, the practice has continually gained ground, until it is now admitted as the most valuable method of treatment. H. C. Wood of Philadelphia, and later Stephen Mackenzie of London, have reported a number of cases in which irrigation of the bowel with large injections medicated with nitrate of silver, drachm j-pint j, was attended with the most surprising results--sometimes but a single injection effecting a cure; and the writer of this article has reported one case almost in articulo mortis where complete cure followed the irrigation of the bowel--on three occasions with three pints of water containing three drachms of common alum. This case was all the more instructive from the fact that a relapse had occurred after very striking but only temporary relief had been obtained with the nitrate of silver, the alum having been substituted simply on the ground of expense.

Salicylic acid has also been extensively employed in this way with the best effects, but carbolic acid has been discarded since the reports of several cases of poisoning have been published. Should it become a question of the necessity of a parasiticide, the bichloride of mercury in extremely dilute solution, 1 to 1000, would be the agent par excellence; but it is probable that the simple flushing of the bowel is the chief {810} curative agent. The use of alum is not attended with the dangers which have ensued from the absorption of carbolic acid, and which might ensue from the bichloride of mercury. The water used in the injections should always be cold. Ice-water injections alone give at times the greatest relief. Wenzel uses injections of ice-water in all recent and acute cases, whether slight or severe--in bad cases every two hours. He seldom finds it necessary to use opium. The object is to introduce as much water as possible without producing too much pain. The large intestine of an adult holds, on an average, six imperial pints, but in the author's experience not more than three or four pints can be safely introduced. The patient should lie upon the back or the left side with the hips elevated and the head low, while the injection is slowly introduced from a funnel, fountain, or a bulb syringe whose nozzle is thoroughly anointed with vaseline. In the absence of a thoroughly competent assistant the operation should be performed by the physician himself, for the proper use of an irrigating enema is a practice which requires both judgment and skill. When pain is experienced, the further influx of the fluid should cease for a few minutes, when it may be resumed again and again until the largest possible quantity is introduced. It is impossible to over-estimate the value of this treatment in cleansing, disinfecting, and constringing the foul and flabby surface of the whole seat of the disease. As was said by Hare, "It changes a huge internal into an external abscess, and enables us to cleanse the bowel of its putrid contents."

Of all the remedies which have been recommended in the relief of dysentery besides the irrigation method, but one, ipecacuanha, deserves the name of a specific. This remedy was first introduced into practice in 1648 by the botanist Piso, who was led to adopt it from the popular praise he had heard of it while travelling in Brazil. He considered it the most exquisite gift of nature, and administered it in infusion according to the Brazilian (subsequently known as the French) method. Légros made three successive voyages to South America to import supplies of the drug to France, but neither he nor the French merchant Grènier, who had brought over more than one hundred and fifty pounds of it, could secure its general use. Thereupon, Grènier acquainted Adrian Helvetius, a Dutch physician practising in Paris at the time, with the wonderful virtues of the Radix dysenterica, who, having experimented with it first upon patients of the lower classes, was later successful in curing the Dauphin of France. The further use of it, by permission of the king, at the Hôtel Dieu, enabled him to secure a monopoly of its sale and secured for him a grant of a thousand pounds. Grènier hereupon put in his claim for a division of the profits, and upon the refusal of Helvetius instituted suit to obtain his rights. Justly indignant at the loss of his suit, he revealed the secret, and ipecacuanha became common property at once. Extravagant ideas were now entertained of its value, but in the extreme reaction which followed every virtue of it was disavowed, so that the drug came to be almost forgotten. From this temporary oblivion the remedy was rescued by an English army surgeon, E. Scott Docker, in 1858, who administered it, in combination with laudanum, in his regiment, on the island of Mauritius, in all cases and stages of the disease with such success that out of fifty cases he lost but one. Although such indiscriminate use and such almost unvaried success has not attended, and from the nature {811} of different cases could not attend, its universal employment, there is no doubt of the inestimable value of the service rendered in the restoration of the remedy in the treatment of dysentery. Yet over twenty years elapsed before its author received from his country, at the urgent solicitation of the Director-General, in recognition of this service, a grant of four hundred pounds.

Remarkable testimony as to its efficiency soon began to appear. Ewart recommends ipecacuanha in every form and type of acute dysentery, as well as in the acute attacks supervening upon chronic cases. Its advantages are simplicity, safety, comparative certainty, promptitude of action, decrease of chronic cases and of complications, especially abscess of the liver, and great reduction of mortality. "It produces all the benefits that have been ascribed to bloodletting, without robbing the system of one drop of blood; all the advantages of mercurial and other purgatives, without their irritating action; all the good results of antimony and other sudorifics, without their uncertainty; all the benefits ascribed to opium, without irritating, if not aggravating or masking, the disease." To the objections urged against it he replies that the nausea is only temporary and evanescent--that vomiting is exceptional and of but short duration; moreover, it permits nourishment and assimilation and produces sleep. If uncontrollable sickness and vomiting occur, they are probably due to abscess of the liver, malaria, some other cachexia, Bright's disease, strumous mesenteric glands, hypertrophy of the spleen, peritonitis, or extensive sloughing.

Cunningham prefaces the treatment by a sinapism to the epigastrium and half a drachm of the tincture of opium. Then from one to one and a half drachms of ipecacuanha are administered in powder. It causes considerable nausea, and vomiting occurs in one to two hours. During the nausea copious perspiration breaks out, the pulse becomes fuller, softer, and less frequent, the tenesmus and abdominal pains cease, and the patient has no more stools for twelve to twenty-four hours. The next evacuation is easy, fluid, but free from blood or mucus. Sometimes the dose of ipecacuanha may require to be repeated.

Malun reports the results of treatment of 436 cases occurring in twenty-one months. There were only 6 deaths, and in only 1 of these could the remedy be fairly said to have failed. Under all other plans of treatment the mortality has varied from 12 to 22.3 per cent.

Mr. Docker says that the mortality of dysentery in the British army during the ten years that followed the adoption of the ipecacuanha treatment fell from 11 to 5 per cent.

The remedy is best administered in large doses, 20 to 40 grains, and should be repeated every four to twelve hours until permanent good effects are secured. A dose of 15 to 30 drops of tincture of opium, or morphia, one-fourth grain hypodermically, will best protect the patient from too great exhaustion. The beneficial results are mostly obtained in the acute cases, though surprising results sometimes follow in cases of very long standing. Thus, Gayton records a case of severe chronic dysentery of eighteen months' duration which was entirely cured by ipecacuanha, and probably most physicians of large practice can recall cases where the continual relapses of the dysenteric habit have been completely broken up by {812} one course of active treatment. Should the remedy fail to be of service in the course of forty-eight hours, it should be discontinued.

Batiator, the bark of the root of the Ailanthus glandulosa; mudar, the bark of the root of the Calotropis gigantea; and bael-fruit, more especially in chronic cases,--have been proposed by Roberts, Duval, Chuckerbutty, and others as substitutes for ipecacuanha, but are not likely to soon supplant it.

Materia medica is rich in drugs whose virtues have been vaunted in dysentery, and cases occur where the judicious physician will make his selection according to the indications in a given case. Turpentine internally, as well as externally in the form of a stupe (Copland), has had advocates from ancient times; astringents, tannic acid or the substances which contain it, kino, catechu, krameria; the acetate of lead, nitrate of silver, etc.; antiseptics, carbolic acid, salicylic acid, boracic acid; anodynes, opium and its preparations; and quinia,--are among the agents most frequently employed.

Bonjean (1870) had occasion to laud the efficacy of ergotin in checking hemorrhage and controlling the discharges in a report which substantiates the claim of Rilliet and Lombard in the epidemic at Geneva in 1853. Massolez had the same good results in the war of the Crimea, as had also Andrea in the Spanish hospitals of Ceuta and Tetuan.

Clysters of nitrate of silver, 4 grains to 5 ounces of water (Duchs), or with a few drops of tincture of opium (Berger); of ipecacuanha (Begbie and Duckworth); of laudanum and starch (Sydenham, Abercrombie); of the various astringents,--may be tried in obstinate, more especially chronic, cases.

Local inspection of the rectum by means of the speculum may possibly reveal an ulcer, which is the chief or sole cause of the tenesmus and bloody discharge. Maury reports such a case in which the ulcer was deep enough to hide a small sponge. In such cases topical treatment may effect a cure.

Dilatation may suffice to overcome a stricture in the rectum, the result of cicatricial contraction, or colotomy may be necessary in cases more refractory or situated higher in the bowel. Post reported a successful colotomy, with the formation of an artificial anus in the left lumbar region, in such a case.

The food should be fluid, but nutritious, and milk best fulfils both these requisites. Where milk cannot be tolerated it may be substituted by soups, beef-tea, mutton-broths, chicken-soup, etc. But it should be known of these substitutes that they contain little or no nutritious matter on account of the insolubility of the albuminoids, and are really only stimulants. Soft-boiled egg, thin custards, sweetbreads, scraped or chopped raw beef--albumen thus in substance--constitute the best food. But during the intensity of an attack the patient should almost altogether abstain from food, both from lack of inclination for it and from lack of ability to digest it. During convalescence the food should be on the basis of animal diet, though ripe fruits and fresh succulent vegetables should not be altogether withheld.

In all cases of pronounced prostration stimulants are to be freely used, and of all stimulants alcohol is the best, as it has also nutritive and {813} antiseptic properties. Alcohol is thus triply indicated in the treatment of dysentery, but the choice of the form and strength will be a matter of judgment in the individual case.