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Home , Bacillary dysentery, Dysentery

71 Postgrad Med J: first published as 10.1136/pgmj.23.256.71 on 1 February 1947. Downloaded from

DYSENTERY AND By SIR PHILIP MANSON-BAHR, C.M.G., D.S.O., M.D., F.R.C.P.

This is an ever-recurrent subject of con- Flexner bacilli, they appear to be less effective siderable contemporary importance and it is in Sonne , which is so prevalent in one which, in view of therapeutic advances, this country at present. There is, however, calls for a periodic review. As a result of the some evidence that the more recently intro- recent war large numbers of ex-Service per- duced compound, phthalystatin, possesses sonnel who have served in , Burma and in greater bacteriostatic powers in this . the Far East are. still suffering from and will However, there is some comfort in the con- continue to exhibit recurring symptoms of templation that Sonne dysentery produces con- these disorders for some time to come. siderably less damage to the bowel surface than Of the bacillary there is for- the other organisms of this group. tunately little to be said. In the acute Whether exposure on a large scale to these dysenteries of bacillary origin a great thera- specific gives rise to a much greater peutic victory has been won by the introduc- incidence of so-called idiopathic ulcerative tion of the special sulphonamides-sulpha- colitis amongst men of military age, which has has guanidine and sulphasuccidine. Not only been recently so much in evidence, remains a Protected by copyright. this disease been robbed of its terrors, but its moot point. It is undoubtedly true that in sequelae, which loomed so large some 25-30 wartime the numbers of a very acute form of years ago, have almost completely disappeared. appear to be increased. I No longer do we encounter those alterations in would like to stress the great importance at the lumen * of the , those arriving quickly and decisively at a correct peritoneal adhesions and that peculiarly in- diagnosis of this fell and insidious disease. tractable ulceration formerly known as chronic The natural tendency is to regard it in the first . Even the granular in- instance, when it arises in those areas where flammation of the lower , or ' granular the other well-ascertained forms of dysentery ,' the unhealed remnant of bacillary are common, as necessarily a manifestation of necrosis of the mucosa, is rarely seen nowadays. one of them. I think this especially applies to These sulphonamides have amply proved amoebic dysentery, but certain it is that, if their worth, of that there can be no question. ulcerative colitis is treated continuously and http://pmj.bmj.com/ And probably also they are not only of curative, successively and mistakenly for amoebic dysen- but also of prophylactic value, because it tery with irritating antiamoebic drugs, such as appears to have been established that by taking emetine and emetine bismuth iodide, its sulphaguanidine in daily gramme doses the manifestations are exacerbated. onset of these dysenteries may be effectually Manifestly amidst such a whirlpool of fluxes prevented. It is due to these measures that itself in war- and dysenteries which presents on September 27, 2021 by guest. the incidence of bacillary dysentery in the time hospitals the onset of idiopathic ulcerative Eastern theatres of war sank, during 1945, to colitis is not readily recognized. Usually insignificant proportions and that the mortality little assistance is forthcoming from . the rate declined to less than I in 5,000. These are laboratory and I am convinced that the most indeed remarkable figures. ready method is by sigmoidoscopy, or even by Though sulphaguanidine and sulpha- proctoscopy. By these means the peculiar succidine are especially valuable in the more plush-like appearance of the mucosa can be toxic bacillary infections caused by Shiga and recognized and its friability and vulnerability Post-Graduate Lecture, Dreadnought Hospital, Greenwich, Sunday, Nov. 3, 1946 POST-GRADUATE MEDICAL JOURNAL February, 1947 Postgrad Med J: first published as 10.1136/pgmj.23.256.71 on 1 February 1947. Downloaded from ascertained. Nor am I convinced that we are be given as an outpatient treatment. A dose of yet in possession of any really effective thera- eight tablets daily for I 5 days suffices to peutic measure in combating its ravages. In' eradicate the infection (i.e. cysts of E. histo- these acute military cases with extreme lytica), whilst in the actual disease-amoebic emaciation and a decision must be dysentery-it appears to exert little beneficial taken early whether operative measures are effect. justifiable or not. Ileostomy may be, and Amoebic dysentery may then appear in many often is, the only practical method of saving disguises. It may, it is true, be severe and the the patient's life, but this must be undertaken resulting passage of bloodstained stools may before the entire mucosa of the large intestine result in emaciation and severe anaemia. has been destroyed or the patient over- More often it is chronic. Then the patient whelmed by toxaemia. suffers mostly from periodic attacks of In less acute cases, or when only limited diarrhoea, abdominal discomfort and some- areas of the bowel are involved-regional times deep-seated'pain confined to the caecum ulcerative colitis-then instillation of sulpha- or sigmoid colon. In my experience acute succidine by rectal retention enemata, in 6-8 abdominal crises, especially when limited to gm. doses suspended in water and mucilage the upper abdomen, are never of amoebic does, for a time at least, suspend the ulcerative origin. process and leads to lessening of the toxaemia. The diagnosis of amoebic dysentery presents Amoebic dysentery is undoubtedly of great many pitfalls. First, the organisms may be importance. The already considerable litera- present in large numbers in the faeces in the active vegetative state, especially when' ture has been enriched by quite a spate of Protected by copyright. contributions on this disease in the current quantities of and mucus are being medical press as a weekly scrutiny of the evacuated. These motile trophozoites are en- British Medical Journal and Lancet amply countered, only in the active acute stage, whilst demonstrates. A great deal of it traverses the precystic and cystic forms are seen in the already familiar ground, though many of our chronic stage when the evacuations are' therapeutic beliefs have been sadly shaken. faeculent. A great drawback to acute diagnosis and a puzzle to pathologists lies in the fact that A fundamental distinction must be made the cysts appear In the faeces in a most between 'amoebic dysentery' and ' amoe- vicarious fashion. It so happens that on one biasis.' The former is associated with' dysen- occasion they may swarm in myriads, whilst tery': the passage of blood and mucus in the in the next they may be absent altogether. It stools, with diarrhoea, colic and abdominal does not appear that the various concentra- pain. The latter is entirely asymptomatic. tion methods which have been devised http://pmj.bmj.com/ The stools may be normal or even constipated, materially help in clinching the diagnosis. So and in them the cysts of histolytica it comes about that the clinician has to concert are discovered by routine examination. I am various examinations, clinical, pathological, in- convinced that these two conditions are patho- strumental and, occasionally, radiographical, logically and therapeutically quite distinct. In in order to obtain a correct diagnosis. I have the former the trophozoites of E. histolytica become increasingly impressed with the value are embedded in the bowel wall and have of proctoscopy. By the judicious employment on September 27, 2021 by guest. seriously affected the mucosa by the cytolysins of this procedure amoebae may often be -they secrete, whilst in the latter the organism demonstrated in cases in which the faeces have plies a coprozoic existence. In the first been examined, often on many occasions, in instance the human host is ill; it may be vain. By proctoscopy, which is so easily per- severely so. In the second he is perfectly well formed, a good view of the rectal mucosa may and is not incommoded. be obtained and microscopic preparations can The distinction has been rendered clearer by be obtained from scrapings of the diseased the introduction of a new quinoxyl'compound surface and the microscopic examination of the -diiodoquin-which contains 63 per cent. of exudate immediately carried out. On many iodine. This drug is easily tolerated and can occasions this simple method is successful in February, 1947 DYSENTERY AND COLITIS 773 Postgrad Med J: first published as 10.1136/pgmj.23.256.71 on 1 February 1947. Downloaded from demonstrating the living and active E. histo- depicted in most textbooks, is an extremely lytica. To perform proctoscopy, a simple rare event. In chronic amoebic dysentery, tubular proctoscope, with obturator, some 6 in. when E. histolytica cysts are numerous in the in length is used. No preliminary preparation faeces, the crenation and folding of the mucosa of the patient is necessary. I find that it is is a prominent feature, whilst the surface is better not to employ a fixed illuminant, such as pitted with innumerable depressions like are fitted into the standard instruments, but an that produced by minute raindrops, giving rise electric bulb introduced within the proctoscope to the classical so-called 'pigskin appearance.' so as to illuminate a limited area of the rectal In this stage it is not possible to demonstrate mucosa. Scrapings can then be made by the trophozoites of E. histolytica in scrapings, means of a long-handled Volkmann spoon of though sometimes precystic forms and cysts any particular lesion encountered. The sample may be demonstrated on the mucosal surface. of mucus, blood and mucosa must be tLans- The only reliable clinical sign, apart from the ferred direct from the bowl of the spoon deep tenderness which has already been re- directly onto a microscope slide, the coverslip ferred to, is the thickening and induration of must be pressed down and no diluent, such as the sigmoid colon, but even this may be saline, employed. The microscopic examina- absent when the amoebic lesions are confined, tion must be immediate, any delay is detri- as they so often are, to the rectum. Amoebic mental. Therefore it is preferable to have the typhlitis is another matter. Here the deep- microscope on a table in the examination room. seated.pain is restricted to the caecum. This If E. histolytica is present, the trophozoites can thickened and tender viscus can be palpated be seen actively progressing between the in the right iliac fossa and it is in this con- Protected by copyright. mucosal cells. I have become increasingly im- dition that radiography may be of distinct pressed with the varying appearances of the advantage. In of the colon it is mucosa attacked by E. histolytica. This arises usually particularly unhelpful. The amoebic from the conviction that the popular idea of caecum (by barium enema) gives a distinctive the characteristic lesions in the bowel are in- appearance. There are filling defects and, on correct. The living pathology differs con- emptying, a spasm is apparent producing a siderably from the morbid appearances. The contracted cone-shaped mass. It is necessary earliest lesions consist of small circumscribed to draw attention to this fact as, in the absence hyperaemic areas, later there are small pin- of direct evidence of amoebic infection by head haemorrhagic depressions which bleed faeces examination, it is particularly difficult when they are swabbed with cotton wool. to diagnose and to differentiate from tubercular The most confusing appearance is in the acute disease. We now come to the vexed and much stage when the is so in- debated question of treatment. http://pmj.bmj.com/ flamed as to resemble the plush-like haemor- A great deal has been heard and written of rhagic stage of ulcerative colitis. Indeed it is the importance of secondary bacterial infec- quite intelligible why so many misdiagnoses are tions. Whilst not denying that these do arrived at on this very .count. Under these actually occur and did play a part in many circumstances, I have learned that it is futile particularly virulent cases invalided from to contuse the mucosa by scraping with a sharp Burma, I do submit that they do not play any instrument to demonstrate the amoebae. The essential part at the present time. Therefore on September 27, 2021 by guest. surface of the mucosa should be swabbed with it is inadvisable to submit the average case of a tightly packed cotton-wool swab, a pledglet intestinal amoebiasis to intensive courses of of blood and mucus removed, and immediately penicillin and sulphasuccidine therapy before examined, Sometimes the amoebae may be so specific antiamoebic treatment is instituted. In numerous as to resemble a solid mosaic of the acute phases emetine injections of hypoder- motile trophozoites. Again the mucosa may mic emetine, at the commencement of treat- present a granular appearance; the surface is ment are, I am convinced, beneficial. After friable as in the chronic stage of bacillary which the routine treatment with emetine and dysentery. Under the present conditions quinoxyl retention enemata should be carried actual ulceration of the mucosa, such as is out on the approved lines. The fault is the 74 POST-GRADUATE MEDICAL JOURNAL Februar) -, i9r, Postgrad Med J: first published as 10.1136/pgmj.23.256.71 on 1 February 1947. Downloaded from present treatment, which has been subjected to due to a specific infection of the mucosa with criticism, lies in the quality and preparation of special preference for the lower . The the emetine bismuth iodide. It has recently later and more familiar phases are probably been shown that it is the dispersibility of the expressions of vitamin deficiencies brought E.B.I. which is the essential factor and the about by the primary lesions. constitution of the covering of the E.B.I. There is another characteristic of sprue tablet. At present Burroughs Wellcome are which appears to me to be almost inexplicable putting out a new preparation which is sugar- on any aetiological basis. may coated and which readily dissolves in the arise de novo and run its typical course, with succus entericus. Some of the older gelatine glossitis, steatorrhoea, emaciation, meteorism capsule preparations had the effect of crystal- and megalocytic anaemia, I5 to 20 years after lizing the contained E.B.I. which then did not exposure to infection. When this occurs it is readily disperse. This new preparation is par- certain to produce very real difficulties in ticularly well-tolerated and can be given in diagnosis. Phantasies of carcinoma of the gr. iii doses, for a total course of 30 gr. I stomach, Addison's disease, anotexia nervosa, freely admit that relapses still occur, but many chronic or pernicious anaemia of these can be cured by a second course. may be conjured up. Then, of course, there is There is one factor to which, I think, too 'little the tendency to classify tropical sprue as idio- attention has been paid. When it has been pathic steatorrhoea, , tubercular ascertained by sigmoidoscopy that the mucosa , or other forms of fatty diarrhoea. is covered by a dense membrane of muco-pus The real distinction lies in this difference. In and detritus then the bowel should be cleansed the vast majority of cases tropical sprue yields Protected by copyright. by high colonic lavage with boracic acid (3i to readily to treatment. Up to the present the the pint) or by 24 per cent. sodium bicarbonate parenteral injection of crude extract has solution, before the E.B.I. course is instituted. held the field. Large doses are necessary, It stands to reason that, unless the bowel 4 c.c. or even more, intramuscularly three surface is reasonably clear, the E.B.I. cannot times a week. Rest in bed and careful dieting come into intimate contact with the diseased are essential. Now at last it appears that a mucosa. In the chronic stage of the disease truly specific treatment is in sight as the out- diiodoquin is of distinct benefit and appears to comc of Spies' work on folic acid. Small doses have a direct action on the cysts. It has been such as io mgm. twice daily for a period of 5-7 shown that I20 tablets of this drug suffices to days appears sufficient. Unfortunately in this clear up the cyst-passer condition. country folic acid (fovite) is very difficult to Tropical sprue is another form of chronic obtain. The exact part that folic acid plays in diarrhoea which has been much in evidence in the cure of sprue is not known. That it has http://pmj.bmj.com/ India and Burma. It has for the first time, in some action in the absorption of fats, possibly the long history of this disease, appeared in in the promotion of 'phosphorylation,' ap- epidemic form and has behaved like an in- pears probable. What is known, and which is fective disease. Large numbers of men were the stricken down at the same time and the disease the most important, it stops diarrhoea, progressed with hitherto undescribed rapidity. reduces the size of the stools, heals the glossitis, The early stages were quite unlike the gener- increases the appetite and promotes haemo- on September 27, 2021 by guest. ally accepted picture. Steatorrhoea did not poiesis. The increase of weight is phenomeral. appear till the dehydration and emaciation It therefore appears probable that the sure were well advarced. It therefore now appears cure of this age-old malevolent and dis- more likely than ever that sprue is primarily agreeable disease may now be in sight.