Present Investigation Indians Next in Order
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666 THE INDIAN MEDICAL GAZETTE [Dec., 1932 THE TREATMENT OF BACILLARY always written up by the physician in charge DYSENTERY BY BACTERIOPHAGE of the case himself. Several cases had to be omitted as so much of the patient's history By F. H. McCAY, m.a., m.d. (Cantab.) ?y was missing. Late Resident Medical Officer, Presidency General and were Hospital, Calcutta Patients of all nationalities ages admitted with dysentery, but the greatest num- The source the clinical material the of for ber were young adult Englishmen, with Anglo- present investigation Indians next in order. One Indian, a hospital The notes of all patients admitted to the sweeper, is also included in the series and was Presidency General Hospital, Calcutta, who nursed in the hospital. It will be noted that were diagnosed as suffering from dysentery there were many more male than female during each of the four years 1928, 1929, 1930 patients. This was due to the fact that there and 1931, have been collected and analysed. were many more male beds available, which Cases of terminal dysentery complicating some reflects in turn the considerably greater number other disease, of simple amcebiasis with no of European men as compared with women in history of passing blood or mucus, of true Calcutta. Especially is this the case during the amcebic dysentery, acute or chronic, and of hot and rainy seasons when dysentery is at its mixed infection have been excluded from the highest incidence and many of the ladies have analysis, and only referred to for purposes of gone off to the more salubrious climate of the comparison. hills. The notes were the work analysed mainly The average Englishman in the East, in con- of the and house of the registrars surgeons trast to those at home, is generally very good hospital and varied considerably, both in at going straight to his doctor when he is ill. the essential quality and quantity. Usually Many of the cases in this series however were points in the history and progress of the case admitted several days after they first passed were given, but often the general condition of blood and mucus. This was due to various the and other details were patient important causes; some patients for instance developed and for instance not, unnecessary particulars, dysentery far out in the mofussil, or at sea, those concerning the patient's family history, and did not reach Calcutta for several days. of stools sometimes appeared. The number Others were treated by their own private doctors was noted on the passed daily temperature more or less successfully for a few days before of chart and details pathological and bacterio- it became apparent that hospital attention was logical investigations and of treatment and diet advisable. were given separately. The diagnosis, dis- Mild cases of can as a rule be charge and result' of treatment were nearly dysentery treated quite successfully in bed at the patients' own homes, and the average case of bacillary dysentery in Calcutta is of this type. For the more severe cases, however, hospital treatment, especially the trained nursing provided, is very much more satisfactory. In addition to the many patients suffering from bacilliary dysen- tery who could not afford private medical attention in the first place, there were during the year a considerable number of room patients in the hospital who were sent in by their private doctors for this reason. In nearly every case there was a clear history of passing blood and mucus, and the more observant patient with bacillary dysentery noticed that he passed pure blood and mucus only and no faeces at all from the very begin- ning of his illness, whereas this did not as a rule happen to the patient with amoebic dysentery until later, i.e., when an ulcer had opened up. Usually diarrhoea was also present ?in bad cases severe diarrhoea, and in extreme- ly toxic ones incontinence. Some patients seemed to make a habit of calling for the bed- pan almost every few minutes, while others probably more seriously ill could control them- selves for much longer intervals. I did not therefore consider it necessary to go too much into individual detail as regards the number of stools passed during the day. In the case notes Dec., 1932] TREATMENT OF BACILLARY DYSENTERY : McCAY 667 the degree of diarrhoea was given to the near- General treatment est ten stools in the hours passed twenty-four General treatment consisted in and the maximum the actual always nursing figure during stay- the in bed till the in hospital has been taken. Abdominal pain, patient strictly temperature was down and the stools had become normal. tenesmus and toxaemia were present in many In incontinent cases the bed linen of the cases to a greater or less completely extent, depend- was in others it was ing on the stage and severity of the disease. changed half-hourly; insisted that the should always be used Unfortunately their presence or absence was bed-pan until orders to the were issued. The not always mentioned in the notes. Generalized contrary diet given was fluid during the acute abdominal tenderness with rigidity was, as a invariably stage and if toxaemia was great the patient was rule, more severe in cases of amoebic rather fed a nurse. I used to order than of because by Personally, bacillary dysentery, probably fluid diet of 6-ounce feeds of a of intestine and also its protein consisting greater length large citrated bael-fruit part was more often involved in the milk, whey, Oxo, sherbet, proximal three hours for adults with former condition. marmite, etc., every ftcxner infections which were commoner than Diagnosis any other sort because the B. jiexner does not There was usually a considerable improve- thrive so well in a protein as in a carbohydrate ment in the condition he was medium. If the culture came back patient's directly ' report put at rest in bed, and sometimes quite a long B. shiga present', I used to give the patient interval before he passed a stool. Unless it a fluid carbohydrate diet in which the feeds seemed a clear-cut case of one sort of dysentery were citrated milk alone or flavoured with tea, rather than the other, I used to withhold every- coffee or chocolate, lemonade, barley water, thing except sips of water until this first stool arrowroot and the like?the shiga variety of in hospital had been passed and seen by some dysentery bacillus preferring a protein to a competent person. If necessary an enema was carbohydrate medium. In other infections and given or a faecal smear obtained from a catheter in acute amoebic dysentery fluid feeds, i.e., both introduced into the rectum. Once the stool had protein aid carbohydrate, were exhibited. In been seen and a definite macroscopic diagnosis the next dietetic stage and in mild cases por- made, which at any rate in early cases was ridge, beaten up egg and milk puddings were quite feasible and only rarely had to be cor- added; next fish and minced meat and finally rected later, routine treatment for either full convalescent diet prior to discharge. amoebic or was commenced. bacillary dysentery Patients were usually allowed to begin to get Some their to have physicians preferred patients up and about directly they felt inclined that treatment?for the example purgatives?from way, provided their temperature was down and start. they had no diarrhoea and-were not passing any In all the cases in a of my series, specimen blood or mucus. If they passed blood or mucus a stool was sent down to the pathological after they were allowed up, i.e., if they relapsed, for examination and culture?in laboratory they were put back to bed and treatment was many cases several stools. The microscopical continued until their motions became complete- examination of the cellular exudate of a dysen- ly normal. Often a little mucus, and sometimes teric stool a an forms rapid and, with practice, quite a large amount, continued to be passed of a easy way arriving at diagnosis. Macro- although the patient looked and felt perfectly cells however have to be phage distinguished well. This was particularly the case in amoebic very carefully from free forms of Entamoeba dysentery but it sometimes occurred in bacil- histolytica; Charcot-Leyden crystals should be lary as well. In the notes of this series of cases for looked and the numbers of blood and pus the dates given for the stools to become normal cells also a present form useful guide. For are taken, like the other details, from the time successful completely bacteriological results the patient was admitted to hospital till the stools must be examined and while fresh plated first stool containing neither blood nor mucus ?at any rate within 4 hours of being passed. was seen by the surgeon or house surgeon, and stool Unfortunately any passed after the labo- this fact was duly charted. I has been closed Occasionally, ratory for the day had to am afraid, this was not until some time after wait till the next and failed to usually grow the event had really occurred, or even not at bacilli. were any dysentery Fresh stools always all, but most of the cases treated with bacterio- sent however when available a and positive phage are detailed fairly well. If a relapse culture result was obtained in a high proportion occurred and a stool containing blood or mucus of cases. Other investigations performed in was passed during convalescence, this fact is were numerous instances routine blood films for taken into account and the extra days are added malarial if the on admis- parasites temperature although many quite normal stools may have sion was over 100?F., blood pictures, especially been passed in the interval.