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constantly quoted because it was scientifically investigated. New arrivals in the tropics are more liable than others, but if we draw a conclusion from the Indian army statistics it would appear that, after eight or ten years' residence in the tropics, liability to the disease is increased. Finally, no age is exempt from dysentery.

Is Dysentery Communicable?—A very important practical question is, whether dysentery is communicable from the sick to the healthy. For my own part I do not hesitate to say that it is. The late Dr. Dryden held this view strongly, and adduces the strongest evidence in support of his assertion, derived from the jail records of India.

We also have the records of the dysentery-stricken Russian troops returning from the Crimea in 1856. They communicated the disease to the towns and villages through which they passed. The herding of dysentery patients together is, therefore, to be sedulously avoided, and this is one of the many difficulties with which the jail medical officer has to contend.

These things being so, it is easily explained why dysentery is one of the terrible pests of the famines of India; of crowded religious camp festivals; of exposed, harassed, and ill-fed armies, as well as of overcrowded jails.

But, beyond all this, dysentery unconnected with such apparent causes, has, on many occasions, spread over countries, even non-tropical countries. We have yet to learn the true etiology of such epidemics.

Diagnosis.-The diagnosis of dysentery requires almost no comment. Very rarely can difficulty arise. Internal hemorrhoids may give rise to hemorrhage and tenesmus, but the diagnosis would be cleared up at once by digital examination. Stricture and ulcer of the rectum is frequently syphilitic; it occurs oftener in women, and there is no great amount of mucus discharge. From diarrhea it is distinguished by the tormina and tenesmus, the abdominal tenderness, and the existence of dysenteric products in the stools. From rectitis, dysentery is known by the absence of general symptoms in the former, and the alternation of natural with dys

enteric stools, and the absence of tenderness on pressure over the colon.


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The symptoms of Bilharzia disease of the intestines may resemble those of dysentery, but that affection is limited to Egypt, Abyssinia, the Cape and Natal. On this point, Sonsin says: "The symptoms often consist of a state of irritation due to catarrh of the large intestine, and especially the rectum. This catarrh must not be confounded with the true dysentery of hot climates, which is present as an endemic disease in countries where the Bilharzia has not been found, and which, even in Africa, often attacks persons not affected by this Yet, the symptoms of the localization of Bilharzia disease in the intestine may resemble much those of ordinary dysentery. Indeed, we often find in the former, as in the latter, a pain with heaviness in the lower part of the rectum, with frequent desire to go to stool, and with evacuations of only bloody mucus; symptoms that present often a chronic course, and that are often accompanied by exhaustion. With the finger introduced through the anus, small soft growths are made out, and if one of these is removed and examined with the microscope, Bilharzia eggs are discovered." Intestinal infection may also cause small recurrent hemorrhages. Prognosis. - As to prognosis: most cases, if encountered at an early stage, will recover rapidly under treatment, and many of the simpler forms will recover without any treatment beyond ordinary care. But when gangrene has already asserted itself, the danger is great; the dark, muddy, red stinking evacuations, containing a large quantity of blackish shreddy sloughs infiltrated with pus, indicate an almost hopeless condition. When a case is about to do well, we soon get intimation; a few hours after the administration of our remedies the tormina and tenesmus become mitigated, if not comparatively trivial. The sign for which the physician is on the lookout is the return of feculence to the motions-a copious pultaceous light brown stool is usually the signal of safety. Superficial gangrenous sloughs in the stools, though giving rise to anxiety, are not to be regarded as of extreme gravity. Such sloughs may be

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recognized from others by the presence in them of intestinal tubules, and the absence of pus infiltration. We may reasonably hope for success when we have this evidence that the gangrenous process has not involved the deeper structures. Signs that a case is going to the bad are quite unmistakable-the quick pulse, the elevated temperature, the hiccough, the shrunken countenance, the apathy, and the cessation of pain, are evidences of sinking that can not be mistaken.

Treatment. It is unnecessary to enter into an account of the modes of treatment practiced by the Ancients and our forefathers; the days of reliance upon calomel, blood-letting, tartar-emetic, and the like, have passed away, and I need not further allude to them.

The modern treatment of dysentery is a combination of rationalism and empiricism; rationalism or common sense as to the indications to be carried out, and empiricism as to the drugs which we employ.

The general indications seem to be plain. We have:

1. To sustain the patient through a very exhausting ordeal.

2. We must try to alleviate his pain which so greatly tends to exhaustion.

3. His diet should be such as will undergo speedy absorption, and leave but little fecal residue to irritate the diseased mucous membrane; and finally,

4. We have to administer medicines which experience has taught us to be specific in their action, employing also, intercurrently, such other therapeutic agents as will alleviate the patient's condition, or control complications which may arise.

As to medicines-but few are requiredcastor oil, ipecacuanha, sulphate of magnesium, or sodium, and occasionally tincture of opium, pretty well exhausts the list of important drugs from which we expect benefit.

Practical Points.-Before entering into the details of treatment, there are a few important practical points which are worth careful attention. The first of these is to lose no time in beginning your specific treatment; a single day, or even part of a day, lost may add immensely to the gravity of the case. A

second point is that you should never allow the idea of using astringents to enter your head: indirectly they are nothing short of poisonous in this disease, and their use would greatly aggravate the patient's sufferings. A third caution is that you do not allow the sufferings of the patient to beguile you into the employment of opium, with the object of relieving pain, except under special circumstances when it is permissible to use it in moderate doses, per rectum. In fact, let your rule be to administer as little opium as possible throughout the treatment.

Acute.-Now, let me ask you to imagine a patient before you with acute dysentery. He has been suffering from dysenteric symptoms for perhaps twentyfour or forty-eight hours. You find him either lying uneasily in bed, with a pinched countenance indicative of pain, or he may be seated upon the commode straining violently, and suffering much. You ascertain how long he has been ill, and then proceed to inspect his stools, the nature of which will enable you at a glance to form some sort of a prognosis

In the majority of cases it is a good procedure, if it has not already been done, to commence with a small dose of castor oil-two to three drachms will suffice- emulsified in a carminative water. This will be all the more necessary if chlorodyne has already been given, as it so often is, as a domestic remedy. The oil usually acts speedily in two or three hours, and by it alone the tormina and tenesmus will surely be considerably lessened.

If the straining be great, and frequently recurring, administer in the first instance an emollient enema-plain, warm water will do very well. The sense of temporary relief will be much greater than may be supposed.

Tormina may be temporarily removed by the application of turpentine stupes to the abdomen. Mustard plasters will not have the same effect. This may seem a small matter, and a homely remedy, but those who have suffered from dysentery, know that it is powerful to assuage pain. The smarting of the turpentine is not heeded-indeed, it is rather regarded with gratefulness so

different is it from the pain which has been removed.

By these simple means the patient's restlessness is subdued. He is no longer obliged to quit his bed every few minutes to strain on the commode, and he obtains some rest, and, perhaps, takes a little needed nourishment.

Before the relieving effects of the fomentation and enema have passed off, the castor oil will have acted, and give a further and prolonged period of mitigation from severe pain.

A couple of hours having elapsed since the last food (and that should have been fluid) has been given, we proceed to administer twenty grains of fresh ipecacuanha powder suspended in a small quantity of water. A period of tranquility should be selected; the most propitious moment to choose is the natural time for sleep, or when the patient seems inclined to doze. Before giving the ipecacuanha draught, the patient should be cautioned to settle himself into a position of repose the moment he has swallowed it; not to attempt to drink any fluid; not to depart from the recumbent position; not, in fact to move at all; nor should any food be given for a further period of two or three hours. He should not swallow the saliva, which will flow freely, but wipe it from his mouth with a handkerchief.

The object of all this is, of course, to prevent the rejection of the specific drug. Many plans have been adopted to further this object, the most common being the administration of a full dose of tincture opii, half hour before the ipecacuanha draught, and the application of a sinapism to the epigastrium; but in the case we are supposing, the minor measures adopted have secured so much comfort that, in most instances, assuming the exercise of a little selfrestraint, not more than a trivial nausea, which ends in sleep, will be experienced. With a view to avoiding opium and frustrating the sensation of nausea, Dr. Birch, late Principal of the Calcutta Medical College, adopted a plan which he informs me acts admirably, and it has the advantage of simplicity. combines a suitable dose of chloral with the ipecacuanha in the draught, and


administers it at the natural hour for sleep, the precaution of the preliminary abstinence from food for two hours previously having been observed. You know that chloral acts speedily, and if the nurse be careful to secure perfect quietude, sleep has taken possession of the patient before the nauseating effects of the ipecacuanha are experienced. The only point to be insisted upon is that no cardiac or respiratory, or other objection as to chloral exists in the case. Among other things, refreshing sleep, of which the patient usually stands in much need, is secured by this plan.

Objections to Opium.-At all events I counsel you to avoid the preliminary opium draught as far as possible, because opium "locks up" the secretions of the liver pancreas and alimentary mucous membrane, and causes the retention of the decomposing debris of which we are anxious to rid the sufferer; moreover, this drug is therapeutically antagonistic to ipecacuanha, which is our sheet anchor. The latter is a gastric and intestinal stimulant, increasing the local secretions and the flow of mucus, whereas the former diminishes the secretions, and intestinal activity is greatly lessened. In fact opium, in this way, rather tends to favor than reduce the inflammation of the solitary and tubular glands. I concur with Dr. Joseph Ewart that "these bad effects often counterbalance the benefits derived from sleep, diminution of peristaltic action, and temporary decrease of tormina and tenesmus consequent upon narcotism. This explains why the real character of the disease is often completely masked by opium, and why apparent amendment is taking place whilst destructive ulceration and sloughing of the mucous membrane is rapidly extending."

Legitimate Use of Opium.-But there are occasions when we gladly avail ourselves of this powerful drug, opium; when hemorrhage, as such occurs, as it does in rare cases; and again opium is permissible and useful in allaying the continued tenesmus of rectitis, and then it is exhibited in an enema or suppository.

Ipecacuanha used in the ways indicated, either alone or in conjunction

with chloral, is simple and safe, and certain, provided the case be taken in time. You need have but little fear of its depressing action. Dysentery patients are credited with exhibiting a tolerance of ipecacuanha.

Saline Treatment.-There is, however, another drug which may be used as a very fair substitute for ipecacuanha in the simpler forms of dysentery, viz., the sulphate of either sodium or magnesium. The French physicians in Algeria and Saigon have recorded very satisfactory results from the former of these remedies, and many of the jail and civil medical officers of India speak very favorably of the sulphate of magnesium; but I think I am right in saying that the majority of practitioners of extensive tropical experience greatly prefer to trust in the seldom failing virtues of ipecacuanha, when they are dealing with the severer forms of the acute disease. A saturated solution equivalent to two drachms, or a little more of either salt is given at intervals of a few hours or oftener till the symptoms yield. I have often employed this plan of treatment with satisfactory results, especially with pregnant women who dread the straining, retching which ipecacuanha might cause. Then, too, the rectal administration of a little opium is permissible.

Dysentery in Young Children.-In the acute dysentery of young children, castor oil given in emulsion in repeated small doses, seldom fails to accomplish a speedy cure-ten minims of the oil every second hour, precautions as to food, rest and warmth, of course, being also followed.

Treatment of the Gangrenoid Form.Should your patient not come under observation till the evidences of a gangrenous condition are elements in the case, we should certainly adopt the ipecacuanha treatment without delay. It is a good practice to employ, also, turpentine combined with small doses of castor oil, during the intervals between the draughts, especially when there is much tympanitis, or a tendency to hemorrhage. The turpentine passes into the bowel, and acts as a disinfectant, or stimulant to the vessels and muscular coat, and a sedative to the local nerves; warm water enemata, to

which Condy's fluid has been added, being also used if the disease be situated low down, or be accompanied with much straining.

Treatment of the Scorbutic.-It is the scorbutic form of dysentery, such as is developed in crowded camps, in jails, and in famine throngs, which proves most refractory to treatment, and yields the heaviest mortality. Of course, antiscorbutic remedies, such as the addition of oranges and pomegranates and onions to the diet, must form an important part of treatment, and the oil of turpentine used as just described, and with the objects indicated, is calculated to do good, but ipecacuanha must be relied upon when there are facilities of comfort, supervision and rest; otherwise it is better to adopt the saline plan, which is more easily carried out upon an extensive scale.

How often is the ipecacuanha draught to be repeated? Very frequently only once each twenty-four hours will suffice, and at most twice in the same interval.

Value of Ipecacuanha.—If the ipecacuanha dose has acted efficiently you will not be left in doubt of that fact, because, after the lapse of five or six hours, the patient will void a very large pultaceous feculent motion of about the consistence of porridge, and not unlike it in color. This we know by the name of the "ipecacuanha stool," which is quite characteristic, and may be regarded as the signal that treatment has conquered.

When Ipecac Fails.-In some cases ipecacuanha will fail, and this may be due to several causes. The case may have existed long enough to have produced an extent of gangrene and sloughing incompatible with the prolongation of life. It may be complicated with abscess of the liver. An irretrievable constitutional scorbutic dyscrasia may possess the patient. Peritonitis or perforation may have occurred; or your patient may be saturated with malaria, in which case you will necessarily include quinine as an essential, perhaps the chief part, of the treatment. These are conditions which render the ipecacuanha inoperative.

Treatment of Amebic Form.-Amebic dysentery is also to be treated with

ipecacuanha, but quinine enemataabout one in three thousand-are to be employed at the same time.

Treatment of Chronic Form.-As to the treatment of chronic dysentery, much will have to depend upon the discretion of the physician. As soon as a patient so affected can be removed from a tropical to an European climate, the better. Change to the hills of India has been found by experience to be unsuitable, and even detrimental. As to medicinal treatment you must rely upon ipecacuanha in frequent small doses-two or three grains-in the form of pills, several times in the twenty-four hours, and adopting an occasional large dose should it be thought desirable, or should an exacerbation occur. Repeated small doses soon establish a tolerance of the drug, and no inconvenience is suffered from the medication, but the dietetic management of the case is of primary importance. You will at times have to give a dose of castor oil, and use a rectal enema of opium. Dr. Maclean recommends the wearing of an abdominal water compress as soothing and supporting. Perfect rest in bed is an essential point unless in very chronic and modified cases, when gentle driving exercise, in a mild climate, is desirable to maintain the general vitality. During convalescence the solution of the pernitrate of iron, as recommended by Maclean, is exceedingly useful. Bael fruit in some palatable prepared form is then, too, of value. When you see a case which has dragged its slow length along, failing gradually, and that the physician has been forced to resort to astringents, such as acetate of lead, copper sulphate, etc., with opium, you may be sure that the end is not far off-the efforts being only to mitigate the patient's sufferings.

Dietary. It now only remains to allude to dietary in dysentery. In acute cases there is no difficulty, because an extreme minimum for a few days can not hurt a person who has recently been in average health, and this is the proper course to pursue. As far as may be, milk diluted, and perhaps peptonized, or alkalinized, should be the food of the dysenteric, but many persons can not digest large quantities of pure milk.

You may then add a thin water arrowroot, and relieve the monotony by allowing a little chicken broth twice daily. Alcoholic stimulants are hurtful-the furthest we may go in this direction is the allowance of a moderate quantity of white wine whey. Beef tea and strong soups are to be avoided. In scorbutic dysentery, milk freely given will constitute an important part of the treatment.

With regard to chronic dysentery it will not be possible to restrict the diet so absolutely. There must be some attempt at variety-but still the rule holds, the more milk the better, but we shall have to utilize raw eggs, puddings of milk and arrowroot, bread, and when possible, white fish, or even a little minced chicken. The ingenuity of the physician and cook will be taxed alike. To the discretion and forethought of the medical attendant, details must be left, but he will have to adhere to the general principles here laid down.

[Written for the MEDICAL BRIEF.] Obstetrics.

BY PERRY WOOLERY, M. D., Heltonville, Ind.

The subject alluded to is a broad one, and one that demands our careful consideration and study. There can be no doubt but that it was a science many centuries ago among the ancient Egyptians. Every case has its peculiarities, and we should ever be on the alert for them, not simply gliding along, depending on Nature for everything. We should be ready for any emergency, and never "lose our head." I have been practicing medicine but a few months, and yet I find many strange things to contend with. My first case was an adherent placenta, but by using strict asepsis, and the best "common sense" judgment that I could sum up, everything was brought around all right. I have, up to this time, delivered thirtyseven babies, the first thirty being males, the remaining seven females. In that number had one case of placenta previa, one case of twins, two cases of adherent placenta, and two with the "caul," which old midwives considered

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