DYSENTERY AND ITS TREATMENT. By Subgeon G. F.
POYNDER,
h.s.
bringing this subject to the notice of the profession through your columns, I have nothing new to offer, or any original suggestions to make ; it is rather with the desire of placing before your In
INDIAN MEDICAL GAZETTE. readers certain methods of treating this often formidable disease which have been found useful that I venture to forward these few remarks. With regard to its etiology, little more can be said at present than that it is in some way connected very closely with a bad water-supply and malarial influence, and may also be influenced very largely by indiscretion in diet. The diagnosis in the acute stage is not difficult ; mucus and blood passed with or without fajces are pathognomic of the disease, or there may be a gelatinous exudation passed (often involuntarily) per anum without any blood. Severe cases also occur where the discharge from the bowels is entirely blood, and may be mistaken for malaria due to other causes than dysentery and where little or no mucus is passed. In doubtful cases assistance may be obtained by washing the dejecta frequently in water and carefully examining the residue as recommended by Dr. E. Goodeve. The symptoms also are, as a rule, very characThe diarrhoea when teristic of the disease. present is accompanied by tenesmus and tormina especially in the region of the colon (transverse), the tongue is usually coated, and there is a general feeling of malaise with increased temperature. All these symptoms are intensified in severe cases, and may be absent, or masked by collapse and great nervous prostration if gangrene of the large intestine should set in early in the disease. "When the patient is first seen it may not be possible to diagnose the disease; the treatment therefore should rather be directed towards the relief of the most prominent symptoms, and this is best done by at once putting the patient 011 some bland and unstimulating diet, as milk, chicken broth, ice, and barley water and at the same time giving a small dose of castor-oil siii with a little peppermint water and syrup ; or a large soap and water enema may be administered, and a mustard plaster applied to the As soon as abdomen for about twenty minutes. the dysenteric products are distinctly recognised in the dejecta, 110 time should be lost in giving small doses of sulphate of magnesia (3*1 every hour), dissolved in a little water, for seven or eight doses till the dejecta become feculent in character and appearance, when it may be followed by Dover's powder in 10 or 15 gr. doses; and if the dysenteric products again appear, the sulphate of magnesia may be repeated as before, or varied with any other treatment at discretion. In ordinary cases the tenesmus and tormina disappear after second or third dose, and after about the fourth or fifth doses usually the fajces become natural in colour, though still very fluid, but improve after a few doses of Dover's powder or chlorodyne. With strong well-made patients and especially those Avho have indulged their appetites too freely, this form of treatment will be
found most causing the
[July
1891.
efficacious, giving great relief and prominent unfavourable symptoms
rapidly to disappear ; but with patients like the poorer classes
weak emaciated of this country,
who appear to live in a state of semi-starvation, this treatment should be used with caution, and discontinued after the fourth or fifth dose, otherwise it is apt to increase the diarrhoea and the abdominal pain. For these cases, and for those where the treatment does not give relief, ipecacuanha should be given in doses of 20 or 30 grains, more than this will probably be vomited, and consequently wasted, besides giving a disgust for the drug which should be given twice a day in the form of pills or boluses, preceded by a dose of tincture of opium to relieve the tendency to vomit. The dose of ipecacuanha may also be combined, with pulv. bismuthi grs. x, and given suspended in a little mucilage with sweetened peppermint water. No food should be given for an hour before or au hour after the administration of the drug, and the desire to drink relieved as much as possible by sipping small quantities of soda water or sucking small pieces of ice. Failing these remedies, or even in conjunction with them, I can strongly recommend a plan suggested some years ago by F. Rawle, Esq., and which I found most useful in the cases in which I tried it. After the injection of pints of water at a temperature of 90? F. (which is usually very grateful to the patient but seldom retained more than five or ten minutes), inject slowly the following mixture: quinise disulph. grs. x, tinct. camp, When slightly co. 31V, decoct, amyli ad 3i. warm this is usually retained, but if not, it may be repeated in an hour or two as required, and if griping pains be felt over the region of the epigastrium, chlorodyne 3 ss. in some aromatic water will give relief. Surgeon Hennie, M.S., in the volume of this Journal for 1886, page 353, very strongly recommends tinct. cannabis indica, which he first heard of from an old Indian resident, as an excellent remedy in this disease, especially in As it is a good subacute and chronic cases. anodyne and antispasmodic, there is every reason to hope that its more extended use may be found beneficial in those forms of dysentery for which he recommends it, and which often tax the capabilities of the medical practitioner very much, as the patient is apt to give up all hope of a cure, finding himself no better at the end of each month than he was the month before. For children who suffer much from this distressing complaint,and which soon becomes chronic in character, I have found large doses of vin. ipecac. 3SS. to 5*1 useful with a little syrup twice or three times a day during the course of the 24 hours, combined with a large hot linseed meal poultice over abdomen, and when the disease becomes chronic, small doses of Dover's
Jrar
POYNDER ON THE TREATMENT OF DYSENTERY.
1891.]
powder
may be
cretae aromat.
If that
given
with bismutli and
pulv.
the germ theory, and believe form of germ 's the origin of this complaint, we may feel inclined to use some germicide in its treatment, of which perchloride of mercury is probably the most patent. Surgeon-Major Moriarty, m.b., speaks very highly of this drug either alone or combined with tinct. cannabis indica, and appears to have had excellent results. Dr. Ringer also recommends this drug highly for the dysenteric diarrhoea of children, giving one grain in 10 ounces of water; he directs a teaspoonful to be given every hour, and for adults j^th of a grain to be given hourly, or every two hours according to the severity of the case. Care must be taken that none of the remedies used in this disease are suddenly discontinued; the dose must be diminished in quantity or given less frequently than during the acute stage, and the dejecta should occasionally be examined to see if the disease is starting afresh. The subsequent debility and anaemia is always more or less marked, and will be best relieved by liq. ferri we
recognize
some #
#
O
pernitratis grs. xv, quini disulph. grs. iii, aq. chlorof. s'i three times daily after food. If, however, this gives rise to dyspeptic symptoms
citrat. grs. vii or grs. viii may milder form of iron. There will, however, be severe cases which appear to defy all forms of treatment by the mouth. For these cases, especially if the ulceration is in the rectum or lower part of the bowel, stronger remedies must be used locally. Surgeon J. Reckitt, M.S. (I. M. J. for 1888, p. 12), recommends "voluminous injections of nitrate of silver," grains 60 to 3 pints of water, and appears to have found them most useful. After repeated attacks change of climate to Eugland, Australia, or the Cape, or even a sea voyage should be strongly recommended and avoidance of the original cause, with careful instructions regarding the wearing of warm clothes (especially flannel around the abdomen) and the exercise of self-denial in order that the desire for harmful food (potatoes) and alcoholic liquors be restrained.
the fer. be tried,
et
or
quini
even some
Illustrative
cases.
Case 1.?On the 13th of April 1891 I was asked to see R. suffering from pain in the left iliac region and diarrhoea, bowels acting three or four times a day with loss of appetite and general debility. She was a Hindoo of about 35 years of age, and had since January suffered more or less from diarrhoea and pain in the side, which continued as a sequel to an acute attack of dysentery early in January. Being anxious to see the nature of the stools before giving an opinion, I prescribed a small quantity of castor oil with laudanum and ordered the stools to be kept
197
for inspection. Diet to be strictly limited to milk and a little chicken broth. 14th April.?Stools fluid, yellowish green i,u colour, and containing a small quantity of blood and mucus. As there was now no doubt that she was suffering from chronic dysentery, I ordered? Siss. Tincfc. Cannabis Indie. R ...
Bismuth. Subnitr. Pulv. Acacia) ...
Syr. Sitnpl. Aqua Menth. Pip.
...
...
? ??
?
...
...
...
...
'ijji.
^i], 3i.
3viii. t, d. One ounce three times a day after food. There was slight relief yesterday after taking the mixture of castor oil and laudanum, but bowels had acted quite as freely as before. ad.
...
April.?Patient much better, pain very bowels acted only twice, feels that the medicine has given her much relief. To have rice, tapioca or sago pudding, with milk and soup. From this date she made an uninterrupted recovery, continuing to take the medicine three times a day till the 25th April, when it was taken twice a day for a week, and on the 2ud May, bowels acting quite naturally, no pain, and appetite good. She was ordered to take the medicine once daily for a week, and as she was quite well, she was discharged cured. Case II.?On the Sth of May 1891 I was asked to see A. S., a tall thin youth of about He stated he had suffered 21 years of age. much from diarrhoea and dysentery the previous day, and was now so weak that he was unable to leave his bed. Yesterday his bowels acted eight times; this morning they acted four times before I saw him. On examining the two motions passed just previous to my visit, I found them very fluid, consisting almost entirely of fluid and coagulated blood mixed with a little mucus. Prescribed mist, cannabis indie, as above, mustard poultice on abdomen, and diet to be restricted to milk and soda water. All stools to be carefully disinfected with carbolic powder. Bowels acted twice during this afternoon, pain and straining somewhat less. Two doses of medicine given. 9th May.?Bowels acted twice during the night; two doses of medicine given this morning. Suffered very much from tormina and tenesmus during the night, for which hot fomentations were applied. As the stools still contained blood and mucus, and as the pain also was not much relieved, the mixture was altered for the following, which was begun at 2-45 P.M. to-day :? 15th
slight,
Be
Magn. Sulpb. Syr. Simpl. Aqua Campb. ad One ounce every hour
did not
act
...
...
...
...
till 9
ipecac, co. gr. xv. at 12 midnight.
p.m.
was
...
...
5yi.
...
...
5V1,
directed. Bowels At 9-30 P.M. pulv.
as
given; bowels acted again 26
198
INDIAN MEDICAL GAZETTE.
10th May,?Patient says he is much better this morning, he took eight doses of mist. magn. sulph. yesterday ; bowels acted this morning at 8 A.M.; the motion was quite fluid and dark green in colour, with a few specks of coagulated milk floating in it. Pulv. ipecac, co, gr. xv. given at 9 a.m. ; mist. magn. sulph. to be given every two hours commencing 10-30 a.m. (3 doses taken.) Bowels did not act all day, nor was To have half an there any abdominal pain. ounce of the mist, cannabis indie, at night, as the full dose, three times a day, appeared to cause slight delirium. Patient much better, bowels acted 11 th May once in the night, motion fluid, had a good night's rest, and feels stronger. To continue mist, cannabis indie, sss. three times a day. 12th May.?Bowels acted once yesterday afternoon (at 5 p.m.); motion somewhat liquid, Feels much no blood or mucus, and no pain. better and stronger ; tongue clean. To have milk pudding and chicken broth. 13th May.?Much better; bowels acted once, motions natural, practically well, except there is weakness. 15th May.?Patient well and fit for work, discharged cured, but ordered to continue mist, cannabis iudic. for three or four days longer. ?
[Jm/?
1891.
POYNDER,
h.s.
bringing this subject to the notice of the profession through your columns, I have nothing new to offer, or any original suggestions to make ; it is rather with the desire of placing before your In
INDIAN MEDICAL GAZETTE. readers certain methods of treating this often formidable disease which have been found useful that I venture to forward these few remarks. With regard to its etiology, little more can be said at present than that it is in some way connected very closely with a bad water-supply and malarial influence, and may also be influenced very largely by indiscretion in diet. The diagnosis in the acute stage is not difficult ; mucus and blood passed with or without fajces are pathognomic of the disease, or there may be a gelatinous exudation passed (often involuntarily) per anum without any blood. Severe cases also occur where the discharge from the bowels is entirely blood, and may be mistaken for malaria due to other causes than dysentery and where little or no mucus is passed. In doubtful cases assistance may be obtained by washing the dejecta frequently in water and carefully examining the residue as recommended by Dr. E. Goodeve. The symptoms also are, as a rule, very characThe diarrhoea when teristic of the disease. present is accompanied by tenesmus and tormina especially in the region of the colon (transverse), the tongue is usually coated, and there is a general feeling of malaise with increased temperature. All these symptoms are intensified in severe cases, and may be absent, or masked by collapse and great nervous prostration if gangrene of the large intestine should set in early in the disease. "When the patient is first seen it may not be possible to diagnose the disease; the treatment therefore should rather be directed towards the relief of the most prominent symptoms, and this is best done by at once putting the patient 011 some bland and unstimulating diet, as milk, chicken broth, ice, and barley water and at the same time giving a small dose of castor-oil siii with a little peppermint water and syrup ; or a large soap and water enema may be administered, and a mustard plaster applied to the As soon as abdomen for about twenty minutes. the dysenteric products are distinctly recognised in the dejecta, 110 time should be lost in giving small doses of sulphate of magnesia (3*1 every hour), dissolved in a little water, for seven or eight doses till the dejecta become feculent in character and appearance, when it may be followed by Dover's powder in 10 or 15 gr. doses; and if the dysenteric products again appear, the sulphate of magnesia may be repeated as before, or varied with any other treatment at discretion. In ordinary cases the tenesmus and tormina disappear after second or third dose, and after about the fourth or fifth doses usually the fajces become natural in colour, though still very fluid, but improve after a few doses of Dover's powder or chlorodyne. With strong well-made patients and especially those Avho have indulged their appetites too freely, this form of treatment will be
found most causing the
[July
1891.
efficacious, giving great relief and prominent unfavourable symptoms
rapidly to disappear ; but with patients like the poorer classes
weak emaciated of this country,
who appear to live in a state of semi-starvation, this treatment should be used with caution, and discontinued after the fourth or fifth dose, otherwise it is apt to increase the diarrhoea and the abdominal pain. For these cases, and for those where the treatment does not give relief, ipecacuanha should be given in doses of 20 or 30 grains, more than this will probably be vomited, and consequently wasted, besides giving a disgust for the drug which should be given twice a day in the form of pills or boluses, preceded by a dose of tincture of opium to relieve the tendency to vomit. The dose of ipecacuanha may also be combined, with pulv. bismuthi grs. x, and given suspended in a little mucilage with sweetened peppermint water. No food should be given for an hour before or au hour after the administration of the drug, and the desire to drink relieved as much as possible by sipping small quantities of soda water or sucking small pieces of ice. Failing these remedies, or even in conjunction with them, I can strongly recommend a plan suggested some years ago by F. Rawle, Esq., and which I found most useful in the cases in which I tried it. After the injection of pints of water at a temperature of 90? F. (which is usually very grateful to the patient but seldom retained more than five or ten minutes), inject slowly the following mixture: quinise disulph. grs. x, tinct. camp, When slightly co. 31V, decoct, amyli ad 3i. warm this is usually retained, but if not, it may be repeated in an hour or two as required, and if griping pains be felt over the region of the epigastrium, chlorodyne 3 ss. in some aromatic water will give relief. Surgeon Hennie, M.S., in the volume of this Journal for 1886, page 353, very strongly recommends tinct. cannabis indica, which he first heard of from an old Indian resident, as an excellent remedy in this disease, especially in As it is a good subacute and chronic cases. anodyne and antispasmodic, there is every reason to hope that its more extended use may be found beneficial in those forms of dysentery for which he recommends it, and which often tax the capabilities of the medical practitioner very much, as the patient is apt to give up all hope of a cure, finding himself no better at the end of each month than he was the month before. For children who suffer much from this distressing complaint,and which soon becomes chronic in character, I have found large doses of vin. ipecac. 3SS. to 5*1 useful with a little syrup twice or three times a day during the course of the 24 hours, combined with a large hot linseed meal poultice over abdomen, and when the disease becomes chronic, small doses of Dover's
Jrar
POYNDER ON THE TREATMENT OF DYSENTERY.
1891.]
powder
may be
cretae aromat.
If that
given
with bismutli and
pulv.
the germ theory, and believe form of germ 's the origin of this complaint, we may feel inclined to use some germicide in its treatment, of which perchloride of mercury is probably the most patent. Surgeon-Major Moriarty, m.b., speaks very highly of this drug either alone or combined with tinct. cannabis indica, and appears to have had excellent results. Dr. Ringer also recommends this drug highly for the dysenteric diarrhoea of children, giving one grain in 10 ounces of water; he directs a teaspoonful to be given every hour, and for adults j^th of a grain to be given hourly, or every two hours according to the severity of the case. Care must be taken that none of the remedies used in this disease are suddenly discontinued; the dose must be diminished in quantity or given less frequently than during the acute stage, and the dejecta should occasionally be examined to see if the disease is starting afresh. The subsequent debility and anaemia is always more or less marked, and will be best relieved by liq. ferri we
recognize
some #
#
O
pernitratis grs. xv, quini disulph. grs. iii, aq. chlorof. s'i three times daily after food. If, however, this gives rise to dyspeptic symptoms
citrat. grs. vii or grs. viii may milder form of iron. There will, however, be severe cases which appear to defy all forms of treatment by the mouth. For these cases, especially if the ulceration is in the rectum or lower part of the bowel, stronger remedies must be used locally. Surgeon J. Reckitt, M.S. (I. M. J. for 1888, p. 12), recommends "voluminous injections of nitrate of silver," grains 60 to 3 pints of water, and appears to have found them most useful. After repeated attacks change of climate to Eugland, Australia, or the Cape, or even a sea voyage should be strongly recommended and avoidance of the original cause, with careful instructions regarding the wearing of warm clothes (especially flannel around the abdomen) and the exercise of self-denial in order that the desire for harmful food (potatoes) and alcoholic liquors be restrained.
the fer. be tried,
et
or
quini
even some
Illustrative
cases.
Case 1.?On the 13th of April 1891 I was asked to see R. suffering from pain in the left iliac region and diarrhoea, bowels acting three or four times a day with loss of appetite and general debility. She was a Hindoo of about 35 years of age, and had since January suffered more or less from diarrhoea and pain in the side, which continued as a sequel to an acute attack of dysentery early in January. Being anxious to see the nature of the stools before giving an opinion, I prescribed a small quantity of castor oil with laudanum and ordered the stools to be kept
197
for inspection. Diet to be strictly limited to milk and a little chicken broth. 14th April.?Stools fluid, yellowish green i,u colour, and containing a small quantity of blood and mucus. As there was now no doubt that she was suffering from chronic dysentery, I ordered? Siss. Tincfc. Cannabis Indie. R ...
Bismuth. Subnitr. Pulv. Acacia) ...
Syr. Sitnpl. Aqua Menth. Pip.
...
...
? ??
?
...
...
...
...
'ijji.
^i], 3i.
3viii. t, d. One ounce three times a day after food. There was slight relief yesterday after taking the mixture of castor oil and laudanum, but bowels had acted quite as freely as before. ad.
...
April.?Patient much better, pain very bowels acted only twice, feels that the medicine has given her much relief. To have rice, tapioca or sago pudding, with milk and soup. From this date she made an uninterrupted recovery, continuing to take the medicine three times a day till the 25th April, when it was taken twice a day for a week, and on the 2ud May, bowels acting quite naturally, no pain, and appetite good. She was ordered to take the medicine once daily for a week, and as she was quite well, she was discharged cured. Case II.?On the Sth of May 1891 I was asked to see A. S., a tall thin youth of about He stated he had suffered 21 years of age. much from diarrhoea and dysentery the previous day, and was now so weak that he was unable to leave his bed. Yesterday his bowels acted eight times; this morning they acted four times before I saw him. On examining the two motions passed just previous to my visit, I found them very fluid, consisting almost entirely of fluid and coagulated blood mixed with a little mucus. Prescribed mist, cannabis indie, as above, mustard poultice on abdomen, and diet to be restricted to milk and soda water. All stools to be carefully disinfected with carbolic powder. Bowels acted twice during this afternoon, pain and straining somewhat less. Two doses of medicine given. 9th May.?Bowels acted twice during the night; two doses of medicine given this morning. Suffered very much from tormina and tenesmus during the night, for which hot fomentations were applied. As the stools still contained blood and mucus, and as the pain also was not much relieved, the mixture was altered for the following, which was begun at 2-45 P.M. to-day :? 15th
slight,
Be
Magn. Sulpb. Syr. Simpl. Aqua Campb. ad One ounce every hour
did not
act
...
...
...
...
till 9
ipecac, co. gr. xv. at 12 midnight.
p.m.
was
...
...
5yi.
...
...
5V1,
directed. Bowels At 9-30 P.M. pulv.
as
given; bowels acted again 26
198
INDIAN MEDICAL GAZETTE.
10th May,?Patient says he is much better this morning, he took eight doses of mist. magn. sulph. yesterday ; bowels acted this morning at 8 A.M.; the motion was quite fluid and dark green in colour, with a few specks of coagulated milk floating in it. Pulv. ipecac, co, gr. xv. given at 9 a.m. ; mist. magn. sulph. to be given every two hours commencing 10-30 a.m. (3 doses taken.) Bowels did not act all day, nor was To have half an there any abdominal pain. ounce of the mist, cannabis indie, at night, as the full dose, three times a day, appeared to cause slight delirium. Patient much better, bowels acted 11 th May once in the night, motion fluid, had a good night's rest, and feels stronger. To continue mist, cannabis indie, sss. three times a day. 12th May.?Bowels acted once yesterday afternoon (at 5 p.m.); motion somewhat liquid, Feels much no blood or mucus, and no pain. better and stronger ; tongue clean. To have milk pudding and chicken broth. 13th May.?Much better; bowels acted once, motions natural, practically well, except there is weakness. 15th May.?Patient well and fit for work, discharged cured, but ordered to continue mist, cannabis iudic. for three or four days longer. ?
[Jm/?
1891.
