with Mayer's reagent.* The advantage of this compound (O20 H3 N2 05, Hg I?) appeared to be

WHAT IS THE RATIONAL TREATMENT 5F ACUTE DYSENTERY 1 WALSH,

By Surgeon J. H. TULL

i.m.s.

was introfrom South been considered as more America, it has always " or less a " the treatment of dysenin specific tery, especially in acute cases. With the introduction of Ipecacuanha, and dependent on it, the treatment by bleeding and mercury salts disappeared?the former for ever; the latter to be revived and maintained as a good and useful method in dysenteric conditions on account of the antiseptic and cholagogue properties possessed by several of the mercury compounds. Even while lauding I pecacuanha as the drug most useful in curing acute dysentery, all writers have acknowledged the very unpleasant symptoms following on its use; depression, nausea, and vomiting sometimes uncontrollable. Some time back it occurred to Dr. Harris, then Civil Surgeon of Simla, that the unpleasant effects of Ipecacuanha would be removed by the extraction of the emetin contained in it and he forthwith put this idea into execution and produced a powder?Ipecacuanha sine emetind? samples of which were sent to various institutions for trial. The results at the Presidency General Hospital were not very satisfactory. What they may have been in other places I cannot say. Subsequently a certain amount of Ipecacuanha was sent by the Medical Storekeeper to Dr. C. J. H. Warden, the Chemical Examiner to the Government of Bengal. There have always been many adherents to the theory that the value of Ipecacuanha, when well borne, was due to the presence of the emetin which,

From the time that duced into European

Ipecacuaiiha practice

acting as an intestinal irritant, caused, perhaps, as a reflex, a free flow of bile and copious stools. Being myself an advocate for this theory, I readily entered into Dr. Warden's suggestion that the emetin, extracted from the Ipecacuanha powder submitted to him, should be used for

treating

cases

of

dysentery combined

as

it

was

that, as the emetin thus combined remains iu, active in the presence of acids, it would not produce vomiting when introduced into the stomach and this supposition seems to have been fully supported by the results in the cases treated. Further, it seemed that Hg I2, a powerful antiseptic, would be an excellent adjuvanTf" Since the early partof December 1890, npinerous cases of dysentery coming under my dave efther in the Presidency Jail Hospital or in my wards at the Presidency General Hospital, have been treated with this emetin mercuric iodide, and the results are shewn in the following table:? Roughly speaking, the proportion of emetin to /Hg I? in one grain of the compound is as ? to f, and for purposes of administration I have used a 2% powder made up with white sugar. At first one or two grains of the sugar powder were given every one or two hours, but after the first few cases, the dose exhibited was ten grains every four hours. Granting eight hours for sleep, which is a large allowance to a patient suffering from acute dysentery, the average amount of the powder taken has been forty grains or nearly a grain of the emetin mercuric iodide. The usual dose of emetin being gr., it will be seen that there can be no suspicion that the drug was inactive. In all cases the administration of emetin was preceded by a castorA strictly fluid diet was also enoil purge. forced with rest in bed. Table I. Cases treated in the Duration of No.

1 2 3 4 5 6

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Hospital.

2 1 6 8 2 7 3 3 9 10 5 4

6 6 10 11 5 15 41 6 13 15

7

10 8 9 5 5 6 11 10

8 6 2 5 3 3 6 4 7

*

Daj'S in

Dysenteric stools.

Presidency

Jail.

Remarks.

Developed pneumonia. Also decoct. Indra jau. Also decoct. Koorchee.

7 6 Died.

No improvement. Released.

Warden: Pham. Jour, and Trans. Ap. 1891, p, 950.

36

270

INDIAN MEDICAL GAZETTE.

Five other cases were treated and recovered, but I omit them, because it is doubtful whether they were cases of true dysentery. Excluding cases 14 and 17, the average number of days during which dysenteric stools were passed was 4'9. I have notes also of twelve cases treated in the Presidency General Hospital. The average duration of dysenteric symptoms was four to five days. Two cases will be given in full, because in these two ipecacuanha siue emetina was first tried, aud also because the amount of emetin taken was larger than usual. A. D. L. I., aged 27, admitted 23rd March 1891. Ill some days with frequent stools containing mucus and blood ; pain in abdomen?>01. ricini 3'iv, Ipecac, s. emetina gr. v every 2 hours. 24th?Says he has been to stool every half hour; stools scanty; pain severe; no sickness, but no improvement after 35 grains of the powder. Emetin mercuric iodide gr. x. every 3 hours. 25th?14 stools, less blood. 26th?Stools still frequent (not counted), but much improved in character; no blood ; painless. 27th?Nine stools; no blood or mucus. Omit emetin and give astringent drink. Was allowed solid food on April 4th. B. T. I., aged 28, sailor, Admitted 3rd June 1891. Ipecac, s. emetiua $i daily for three days. No sickness, but no improvement. 6th ?01. ricini siv. Emetin mercuric iodide gr. x every two hours. Improved steadily. Given fish on the 15tli. I next propose to give a Table, shewing the results in a certain number of cases treated in the Jail Hospital with Koorchee, the bark, and Indra jan, the seeds of the Holarrhena antedysenterica, Wall.* These cases were taken as control experiments while the emetin was being used. Table Duration of

No.

Dysenteric stools. 4 5 4 2 13 9 4 6 4 12

II.

Days in Hospital.

Remarks.

Indra

8 12 11 5 29 10 6 7 (i 14

jau.

Koorchee.

but the average duration of 5'7 stools days was higher than in dysenteric the cases treated by emetin. For other cases treated with Koorchee and Kurchecine, see Indian Aledical Gazette, 1880, p. 308, aud 1881, March Number. All

*

"

called

recovered,

Pharmacographia Indica," Vol. ii, Wrightea Antedysenterica.

p, 391.

Also

inaccurately

[Sept.

1891.

From Tables I and II it must be inferred that

although emetin mercuric iodide seems a useful drug, it is not proved to be much better than preparations of Wrightea Antedi/senterica, and I do not claim any preeminence for it, nor do I recommend it above other drugs. It is not even

be better than other drugs which are to have any " specific" action on This proposition brings conditions. dysenteric me to the point at which it becomes necessary to face the question with which this paper is headed. I cannot, of course, review every published case, but I will draw attention to some recent statistics which will be quite sufficient as a foundation whereon to frame a reply. In the Indian Medical Gazette for 1882, p. 90, there is an article on the treatment of dysentery by Dr. Owen, who at the time was second medical officer at Port Blair. He treated 151 cases of dysentery with tincture of aconite and with A strictly milk or one exception all recovered. milk and rice diet was enforced, and the average number of days under the aconite treatment was 4*05 ; slightly better than in my cases treated with emetin mercuric iodide. It must, however, be noted that the cases appear to have The amount of tincture been of a mild type. of aconite consumed by individual patients varied from m.vii to gvi, m.xxii and the average quantity taken was 31 m. l. So satisfactory did Dr. Owen find this method of treatment that he discontinued the use of ipecacuanha. On referring to the Medical Annuals from 1888 to 1891, I find some twenty or thirty drugs recommended for the treatment of dysentery, and many of these differ as the poles in their therapeutic action. Dr. D. M. Dolgopoloff of Knisk, treated 140 cases with napthaliu. Dr. Reimie advocates the use of tinct. cannabis indica (Indian Medical Gazette, 1886, p. 353). Numerous authorities suggest astringent injections, and finally we have a paper by Surgeon A. W. D. Leahy, (Lancet 1890, p. 711), advocating the treatment of acute dysentery by frequent doses of a saturated solution of sulphate of magnesia combined This thoughtful and with dilute sulphuric acid. interesting paper is well worth reading, and his statistics shew that, in his hands, the treatment has been very successful. Surgeon Leahy treated 95 cases with only three deaths, and it would appear that the mixture was giveii every hour until the stools ceased to be dysenteric in charThe average time required to attain acter. this end was about two days. Mr. Leahy sums up the advantages of this treatment over ipeca-

proved

to

cuanha

as

not

"

supposed

follows

:?

(1) It has 110 depressant action on the system. (2) It neither produces nausea or vomitting. (3) It quiets and soothes the patient. (4) Its physiological action 011 the mucous membrane of the intestines in relieving hyperemia

Sept.

1891.]

WALSH ON THE TREATMENT OF DYSENTERY.

is

sound, and by this means it probably prevents the formation of ulcers within the gut, places those which may have already formed into a condition most favourable for their healing, preventing the acute inflammatory process and engorgement of the mucous membrane leading to the death of more tissue and thus bringing about a cure." In the Indian Medical Gazette for July 1891, Surgeon Poynder, M.S., gives notes of a case treated with sulphate of magnesia and tincture of cannabis indica. Further, in the same article, he draws attention to the use of injections in cases which do not yield to drugs given by the mouth. The conclusion which the reader may now have arrived at, from the instances of varied treatment to which I have alluded, will, no doubt, be that it would be well to give up our faith in any one particular drug and work on scientific principles in treating acute dysentery, using whatever means may be available at the time. Acute dysentery is, in my opinion, a local disease, sometimes accompanied by secondary febrile symptoms, affecting usually the rectum or lower part of the bowel, rarely the whole of In mild cases there is the large intestine. tumefaction, inflammation, pain and excess of secretion or mucus, often streaked with blood. A stage further and we get extreme local congestion with ulceration and destruction of the intestinal mucous membrane, which may be accompanied by more or less haemorrhage. If such pathological conditions occurred in any other part of the body, we should aim at procuring local cleanliness with local and general rest, and should treat febrile symptoms if necessary as they arose. Why then should we not be content to apply the same principles to the treatment of acute dysentery ? Cleanliness can be obtained by a purge such as castor-oil or sulphate of magnesia. Rest is always insisted on by allowing only a fluid diet and by keeping the patient in bed. With the fluid diet may be given a simple antiseptic or mild astringent; but, on the whole, in slight cases, the less the patient is troubled with drugs the better. I do not wish to be " thought an advocate for what is called the ex-

pectant" treatment, although, no doubt, many would get well on a milk diet only ; still I think that even mild cases will get better in a shorter time if assisted 011 rational principles; and cases

these principles are adhered to, I think it matters one straw what drugs you use, or whether these drugs are given by the mouth or in the form of injections into the lower bowel. The method of treatment by injections will, however, as pointed out by Dr. Cronibie in the Medical Annual for 1891, only be effectual when the dysenteric lesions are low down. One word as to cases in which extreme hasmorrhage occurs. Haemorrhage iu dysentery must be so

do

long

not

as

271

on general principles, and ergot with or hazeline, together with astringent injections, give the best results. There is also another point always to be kept in view, and that is

treated without

that careful treatment in acute dysentery and especially long rest in bed on a fluid diet will prevent or at least diminish the chances of subsequent chronic dysentery. After the stools have ceased to be dysenteric in character, the fluid diet should be continued for at least a week, especially with Europeans.

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