Pike Report GEA – Appendix 9

NOTES ON DISEASES by Lieut-Col Andrew Balfour, CMG, RAMC
A note on dysentery by Lieut-Col Andrew Balfour, CMG, RAMC

Such evidence as is forthcoming goes to show that Bacillary Dysentery is the type most prevalent in this country as is also the case in other war areas.

At the same time a certain amount of amoebic infection exists and it is of great importance not only to recognise the nature of the infection but to treat the latter on proper lines without undue waste of expensive drugs like emetine, and yet, in the case of amoebic infection, as thoroughly as possible in order to get rid of cyst carriers. These constitute a danger not only to themselves but to the community. In many cases it is impossible to distinguish bacillary from amoebic dysentery by clinical examination alone and further it must be remembered that mixed infections occur.

Still in a good many instances a correct diagnosis may be made even without the microscope if the following points are borne in mind:-
1. A raised temperature, at least to any extent, is not a feature of uncomplicated amoebic dysentery. Bacillary infections on the other hand usually exhibit at the start a considerable elevation of temperature.
2. Owing to the large cellular exudate in the stool of bacillary dysentery, and exudate consisting of pus, epithelial cells and large macrophages, the mucus of a bacillary stool is usually white in colour. The typical bacillary stool is small, white or whitish, presenting a more or less jelly-like appearance and contains streaks or spots of blood.

The typical amoebic stool is very different. It looks much more faecal for it is brown or greyish green in colour and the blood and mucus are more intimately mixed than is the case in the bacillary stool.

It takes, however, a certain amount of experience to recognise these differences unless they are very marked and hence, wherever possible, it is of the utmost importance that the stool should be examined microscopically and as early as possible in the course of the disease.

Treatment of Bacillary Dysentery
It is not intended to enter fully into the subject in this short note but it may be said that the great majority of cases readily yield to the well-known saline treatment. It would seem that in mild cases of bacillary dysentery emetine is beneficial but as perfectly good results can be obtained by the use of sodium or magnesium sulphate, emetine should be reserved for amoebic cases unless the diagnosis is doubtful. One drachm of the salt in a suitable mixture should be given every four hours at first or even more frequently. Later on increase the intervals between the doses but continue till the stools become watery and bile-stained.

In severe cases of bacillary dysentery emetine is useless and probably harmful and recourse should be had as early as possible to the subcutaneous or intravenous injection of anti-dysentery serum. The fresher this is the better, and it should be noted that the dosage marked on the vials is too small. Experience has shown that the initial dose should be at least 40 cc or 60 cc. In very bad cases 100 cc may be given at once. If immediate improvement does not result the dose should be repeated and if thought advisable increased on the following day. As much as 400 cc of serum have been given in very bad cases and it has apparently effected a cure.

In cases severely drained by the dysentery and where there is much tenacious mucus and dark decomposed blood in the stool or where much dark bile is present staining the mucus, the administration should be intravenous. In such cases the intravenous infusion of normal saline either with or without the serum is also of value and recourse should be had to it sufficiently early for there is no use waiting till the patient develops a Hippocratic countenance.

Treatment of Amoebic Dysentery
The only point to which reference will here be made is the use of emetine which is our sheet anchor in amoebic infections. At the same time it must be used intelligently and without undue waste of a valuable drug which it must also be remembered is distinctly toxic if given in too large doses or continued for too lengthy a period.
Emetine will quickly abolish the symptoms of amoebic dysentery but this is not tantamount to saying that the patient is cured of his infection. Experience during the present war has shown that in the great majority of cases in order to get rid of amoebic cysts some of the emetine at least must be administered by the mouth.
Now the presence of cysts indicates that there are still living amoebae in the bowel producing these cysts. The emetine does not act on the cysts themselves but on the vegetative forms which if untreated pass into the cystic stage. Kill them and no cysts will be found. The presence of cysts also indicates that the patient continues to be a danger to himself and to the community amongst which he lives. He is a danger to himself for so long as he harbours cysts and therefore living amoebae, he is apt to relapse and may develop liver abscess. He is a danger to the community because it is in the cyst form that the amoeba passes from the sick to the healthy either through the agency of flies or directly through the medium of food, water and possibly dust. To abolish symptoms and get rid of cysts give emetine in either of the following ways and where possible get the treatment controlled by microscopic examination of the stools:-

1. Give 1 grain of emetine hydrochloride by the needle in the morning and ½ grain by the mouth at night daily for 12 consecutive days. The oral emetine should be administered in the form of Keratin-coasted tablet. If these are not available the ordinary injection tablet can be coated with salol. Vomiting may be induced by this method but is not a contra-indication. Tolerance is usually established. The course should not be shortened even if all symptoms disappear. In many cases saline may with advantage be administered at the same time but if the (p126) oral emetine proves somewhat laxative, as is often the case, they need not be given.

2. Give the new double iodide of emetine and bismuth in 3 grain doses daily by the mouth and continue it for 12 successive days. This treatment often causes vomiting at the start, but the usual measures should be taken to prevent its occurrence as far as possible and the drug should be continued. Here again the tablets can be coated with salol.

As the double iodide is not yet available in this country recourse should be had at present to the first of the two methods described. If oral emetine cannot be obtained ipecacuanha should be given by the mouth.

Note on the treatment of Malaria
Experiences in several of the war areas during the present war have modified in certain directions the views previously held as regards the treatment of malaria, whether of the primary acute attack or of malarial relapse.
The most important fact which emerges is the absolute necessity of treating the initial malarial attack early, intensively and continuously. Of scarcely less importance is the necessity for ensuring, as far as possible, that during the treatment the patient is kept in bed for a sufficient length of time.
It has very recently been shown that to obtain the best results and to obviate the risk of relapse the patient should be given 30 grains of a soluble salt of quinine daily for a period of three weeks.
If it can possibly be managed he should be kept strictly in bed for a fortnight from the commencement of this treatment.

Oral Quinine
The soluble salt, if it can be obtained, should be employed in solution. Pills and tablets are not recommended but if they have to be used they should be crushed before administration.

It is important to give a preliminary dose of 2 or 3 grains of calomel followed by a saline aperient and this may be repeated once a week.

The bi-hydrochloride is the most soluble salt of quinine but the bi-sulphate is quite satisfactory. The sulphate should be avoided if possible for it has to be given in acid solution (m1 of acid suplh dil to each grain of quinine) and this tends to disorder the stomach.

Symptoms of cinchonism may develop but, unless severe and continued, are not serious. If tinnitus proves unpleasant it may be controlled by hydrobromic acid or one of the bromides.

In most cases the quinine can be taken perfectly well by the mouth. If vomiting is troublesome give a small teaspoonful of bicarbonate of soda in warm water. If it rejected repeat the dose. Then give a stomach sedative. In severe vomiting wash out the stomach or try small doses of Tinct iodi well diluted or blister over the line of the vagi in the neck. The 30 grains of quinine may be (p127) given in 10 grain doses thrice daily but when it is possible there appears to be an advantage in giving 6 doses of 5 grains each.

If blood examination shows that the above dosage is not ridding the blood of the intracorpuscular parasites, as much as 15 grains may be given thrice a day or recourse may be had to the needle (vide infra). Remember that the failure may be due to a poor preparation of quinine or to lack of absorption. The latter can often be obviated by combining the quinine with iron and strychnine or giving it along with stimulants such as ginger, camphor or capsicum.

Along with the quinine, arsenic should be given from the outset, beginning with two minims of liquor arsenicalis thrice daily and gradually increasing the dose. When the patient is admitted to hospital his skin should be got to act freely and he should be given plenty of warm fluid to drink. Caffeine and antipyrine, phenacetin or aspirin are useful for the relief of headache. The diet should be fluid until the paroxysm has abated.

As it is difficult under active service conditions to carry out the above treatment fully and thus effect, in the majority of aces, a definite cure, it will often be necessary to continue the quinine after convalescence is established.

Where it can be managed, quinine in effervescing form will be found useful at this stage, the drug being combined in a powder with citric acid and taken dissolved in a mixture containing carbonate of ammonia and potassium bicarbonate. There is no use carrying on with small and inefficient doses. It is advisable to give not less than 15 grains a day and it seems better according to recent experience to continue with this dosage for three months.
In some resistant case or when the quinine is badly borne, it will be found useful to combine the drug with a little opium or with alkalies or, as has been said, with carminatives. Warburg’s tincture (1 drachm every 4 hours for a few days) will sometimes succeed when quinine alone fails. The tincture contains quinine, opium, camphor, and other stimulant substances.

In addition the convalescent patient should be given iron and continue his arsenic. There is always some anaemia after a malarial attack and it is important to exhibit blood tonics. A useful mixture is:-
Ferri et ammon citratis, gr 10
Liq arsenicalis m 3
Aq ad, fl oz 1
Sig tds after meals.
If the spleen remains enlarged and the patient is rather cachectic he may be given the following:-
Quinine hydrochloride, gr 5 to gr 7
Acid arseniosi, gr 1/36 to g 1/24
Pulv ipecac co, gr 3 to gr 4
Hydrarg subchloride, gr 1/10 to gr 1/6
Ft Pulv in cachets.
Sig. One at 11 a.m. and another at bed-time.

In severe cases with marked jaundice as in the form of malaria known as Bilious Remittent Fever where the liver is thrown out of action, glucose should be (p128) given either by the mouth or in the form of raisin tea or as a glucose solution or by the bowel in 5 or 10 per cent solution. It may also be given subcutaneously or intravenously.

What used to be known as the Algide type of malaria, which may develop several weeks after the initial attack, has been shown to be due to malarial infection of the suprarenals and should be treated both by quinine and by adrenalin. The latter should be given either intramuscularly or intravenously (m 5 of 1-1,000 solution). Adrenalin by the mouth is often quite inert.

Intramuscular Quinine
Although, as stated, quining by the mouth is usually perfectly well tolerated and quite efficacious, there are certain conditions when recourse should be had to intramuscular injection. These are:-
1. When the oral administration after careful trial in full doses has failed.
2. When oral administration is contra-indicated owing to severe vomiting or gastritis. Such cases are rare.
3. When for any reason intravenous injection cannot be given in grave cases of cerebral and algide malaria.
4. When a patient who has had malignant (sub-tertian) malaria is in a state of chronic cachexia, has crescents in his blood and is not benefited by oral administration. This is the kind of case which has not been properly treated at the onset.

It is not considered necessary here to detail the technique required but due care must be given to steralization of the needle, the syringe, and the patient’s skin. The needle, a long one, should be inserted at right angles to the skin and pushed well home into the muschle, either into the gluteus maximus about two inches below the middle of the iliac crest or into the deltoid an inch or two below the outer border of the acromion. Carefully avoid the regions of the sciatic and musculo-spiral nerves. The usual dose is 15 grains, preferably given as two injections of 7 ½ grains, each but if considered necessary doses of 30 and even 40 grains may be employed.

Intravenous Quinine
The intravenous route is indicated in severe cases of cerebral malaria with coma or convulsions or where such complications are threatening; also in bade cases of algide malaria characterised by collapse, sub-normal temperature, low blood pressure, vomiting, diarrhoea and lumbar or epigastric pain. The technique need not be described in great detail. The cephalic or median basilic vein should be selected and distended by the pressure of a bandage applied round the limb above. Every care must be taken as regards steralization, and the needle must be specially sharp. All air bubbles must be expelled both from the syringe and the neede. To make sure the needle is in the lumen of the vein withdraw the piston of the syringe slightly. If a little blood flows back into the glass barrel it is safe to proceed with the injection which must be made very slowly and carefully after the bandage has been relaxed. Quinine bi-hydrochloride is used, the usual dose being 10 to 15 cc of warm sterile salt (p129) solution. It is an advantage to add 0.25 per cent of sodium bicarbonate to neutralise the acidity of the quinine solution but this is not absolutely essential when the above dilution is employed. Stronger and also more dilute solutions of quinine can be safely used, and larger doses can also be given, but the above is a good routine method. In bad cerebral cases a quantity of sodium bromide equal to the amount of sodium chloride in the saline may prove beneficial. The injection can be repeated if necessary every 6 or 8 hours.

If there is hyperpyrexia, ie, a temperature above 105◦ F associated with delirium, the patient must be cold sponged or rubbed with ice. When it can be managed a cold bath together with a vigorous shampoo of the whole body is the best measure. The temperature must be taken in the rectum and the patient put bac in bed when it falls to 101◦ or 100◦. It will continue to fall after removal from the bath. Hyperpyrexial cases should on no account be moved unless the military situation renders their transfer imperative. This should also be a maxim in all cases of black water fever.

In cases of insomnia and restlessness morphia in doses of 1/3 grain is often valuable.

Malaria Relapses
These are to be treated on much the same lines as the initial attack; the dose of quinine should not be less than 30 grains daily, preferably given in six does of 5 grains each, and continued for at least 3 weeks, arsenic being given at the same time as already detailed.

In cases of chronic relapsing malaria it is often advisable to try one or the other of the organic preparations of arsenic. Perhaps the best is Arrhenal (methyl arsenate of soda) in doses of half a grain six hourly by subcutaneous injections for two days. Sometimes it is well to give this drug before starting on a course of quinine.
In very resistant cases it is justifiable to give a regular course of intravenous injections alternating with quinine by the mouth, but this can only be carried out at Base Hospitals. Other measures such as the exhibition of iron, stimulating adjuvants and special preparations of quinine have already been mentioned.

The following method of preventing the chigger gaining entrance to the skin is recommended as one which merits a good trial:

Wash the feet thoroughly and then rub in a mixture consisting of 5 drops of Lysol or of liquor cresol saponatus in 1 ounce of Vaseline. Special care should be taken to treat in this way the spaces between the tows, and the undersurface of the toes. It is said that this method will afford protection for three days. It has also the advantage that any chiggers which have penetrated the skin before its application are killed and can be more easily and painlessly extracted than when alive.

1st Printing Co, RE, B Army Sec, No 659

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