long as there is any secretion. Hydrogen dioxide, carbolic acid, to 5 per cent., iodoform ointment (4 per cent.) have their advocates. Protect the other eye, if only one is affected (very rare).

Lenow Building.

THREE MONTHS OFFICE EXPERIENCE

IN THE TREATMENT OF CHRONIC DYSENTERY.*

BY JOHN L. JELKS, M.D.

MEMPHIS.

Surgeon in Pelvic Diseases to the Shelby County Poor and Insane Asylum; Surgeon to the Old Men's Home; Fellow of American Proctologic Society.

DYSENTERY was one of the best known and perhaps best understood diseases of antiquity. The gravity of the disease also has always been such, and is today, that this subject is rendered too broad to confine one's remarks to a brief thesis merely, but there are a few facts and ideas to which especially I desire to call attention. A brief retrospect of the history of the disease would not be amiss here, therefore I quote Dr. W. W. Johnson, who, in the Reference Hand-Book of Medical Sciences,

says:

"It was well known before the time of Hippocrates, 430 B. C., but this writer was the first to give an accurate description of its symptoms. He clearly differentiates it from diarrhea, as the following extract from his works show: But when the body being heated, acrid matters are discharged, the intestine is excoriated, ulcerated and the stools are bloody, this is dysentery, a grave and dangerous disease,' etc. From the time of Hippocrates to that of Celsus, 25 B. C. to 45 A. D., the contention of schools and theorists did but little to advance medical knowledge, but the writings of the 'Medical Cicero,' as Celsus has been called, may be said to epitomize the learning and practice of his predecessors, and that the chief features of dysentery were then understood. Aretaeus (50 A. D.) recognized without doubt by actual observation that the ulcer was the peculiar and dangerous lesion of the intestine in dysentery. A century later Galen (164 A. D.) said that physicians

Read before the Mississippi Valley Medical Association, Kansas City, Mo., October 17, 1902.

of his time limited the term dysentery to cases of intestinal ulceration. Alexander, of Trallus (575 A. D.), distinguished dysentery in which various humors are discharged by stool, from the graver variety due to ulceration of the bowels, in which shreds of the intestines are mixed with the discharges. Other writers of antiquity, as Paulus Aegineta (660 A. D.), who made tenesmus and dysentery separate affections; Fornelius and Fabricius Hildanus gave more or less accurate definitions of the disease and of its characteristic phenomena."

Thus the author quoted leads us down through the ages to the present time, and in passing mentions the first post-mortem examination of subjects, who were known to have died of this affection, as referred to by Antonio Benivieni in 1506; also the writings of Hallerius, 1565; Schenckius, 1584; Sennertus, 1626; Sydenham, 1672; Bonetus, 1679; and Morgagni, 1762; that following these came a host of writers who added much to the clinical knowledge and therapeutics of dysentery by a large experience in epidemics in Europe, India and Africa, and in armies and fleets; and that among those of whom special mention should be made are: Digner, 1743; Pringle, 1752; Vogel and Mayer, 1765; Zimmermann, 1765; Stoll, 1780; Rollo, 1786; Hunter, 1796; Desgenettes, 1802; Fournier and Viday, 1814; O'Brien, 1822; Annesley, 1828: Cruveilheir and Virchow, 1842; Cambay, 1847; Catteloup, 1851; Dutroulau, 1861; Heubner, 1871; Woodward, 1879; Favrer, 1881; Kartulis (in Egypt) 1885; Councilman and LaFleur, 1892; Ogata and Shiga, 1897, in Japan; Flexner, 1890; Strong and Musgrave, 1900, in the Philippine Islands.

I have thus trespassed upon your time to set forth more clearly the magnitude of this subject upon which so many volumes have been written by abler writers from the days of Hippocrates to the present; however, my excuse for selecting this subject is made in the recitation of facts relative to the treatment of this disease, for my belief is that if, during the war between the States and the Hispano-American War, and especially during the various epidemics in this and foreign countries, different ideas as to treatment had been conceived and practiced, not so many deaths would have been recorded. In thus confining my remarks to the treatment, I would not

engage the thoughts of my hearers in the multitudinous etiological factors and the gross and microscopic pathology of the disease, though to properly treat such cases, one must have a correct idea as to these from the beginning, and during all stages of the affection. Whether the disease be due to the Ameba dysenteria, or to the Bacillus dysenteria, or of any other microbic origin, we grant, as do all authors, that each is due to infection by some specific microorganism, and this concession is the basis of all treatment which tends to shorten the duration and lessen the severity of an attack.

Whether the disease be classed among those of sporadic dysentery, such as we encounter especially during the summer and autumn months in the temperate and tropical climates, or occurs as epidemics and of the gravest types, such as that referred to by Shiga in Japan in 1897, when 22,300 deaths24 per cent.-occurred out of 89,400 cases, the same general idea must obtain as to treatment; however, of course vast differences as to pathology in the different forms and stages of the disease would require a like classification of treatment, but with the same ultimate object in view, viz. the destruction of the microorganism, cleanliness, rest and restoration of the diseased tissue.

Primarily, it is necessary for me first to briefly consider the subject of acute dysentery, by way of introducing my subject proper―chronic dysentery.

In the beginning of an attack of endemic dysentery, such as we see especially during the summer and autumn, very little pathology is noticeable to one making a macroscopical examination of the affected intestine. The mucous membrane is as yet intact, and is devoid of those grave pathological appearances noticeable in other varieties or in the same case later in the attack. For as yet the serum simply pours out of the swollen mucous menbrane as water is squeezed from a sponge, and the membrane seems studded with minute hemorrhagic puncta, and notwithstanding the great exosmosis of this serosanguineous fluid, the membrane remains congested and thickened, and if this great engorgement is not relieved, destruction, first of its epithelial covering, and then of the entire thickness of the mucosa, follows. Here the homeopathic idea, while

erroneous in fact, would appear correct as to the result, for every physician recognizes the condition and immediately administers drugs which increase the exosmosis, the favorite prescription being magnesium sulphate, with the very apparent and common result of aiding the vessels of the intestines to empty themselves, and of depleting the mucosa. Here, and perhaps without such purpose in view, the microorganisms which bear a casual relationship to the disease are washed away by the free saline catharsis. If the dysentery has been preceded by a diarrhea, and the colon is thought to have been emptied, small doses of castor oil may be preferred to salines.

Entering further into the recent ideas of treatment in the early stages is the administration also of such antiseptics as mercury, salol, guaiacol, zinc sulpho-carbolate, and a host of other drugs which are of undoubted benefit in selected cases. It has been the custom among physicians for many years to administer enemata of starch water, infusions of flaxseed or slippery elm, added to which some give opium in one of its forms. But the local treatment of these, or of graver forms of the disease, has scarcely extended beyond this. The erroneous idea has been that the disease, though affecting the larger bowel, and especially the rectum and sigmoid flexure of the colon, was beyond any possible local application, further than perhaps the use of the Wales metal bougie, which in the majority of cases positively would be dangerous, while the bowel is in this highly inflamed state.

I have recently suggested to one of my confrères the value of local treatment in connection with administration of drugs by the mouth, when his ready response was that he could not get at the seat of the trouble. Those who have used the sigmoidoscope and long rubber tubes know as I do that my friend in this statement is mistaken, and here the need is made apparent of the education of the profession as to the possibilities. of the surgeon's efforts when armed, as he must be, with the proper and essential instruments, and is expert in their usage

Not so much need of these instruments is apparent here, however, as in the sub-acute or chronic forms, and in other graver forms of the disease, and I make this distinction because of my belief that in those grave forms of the disease when in a few VOL. XXII -46

hours the patient would succumb, no great time should be lost in dealing with the condition as necessity may require. In setting forth my idea as to the treatment of dysentery it must be understood, first, that no iron-clad or routine rules of treatment can be laid down. To the contrary, and notwithstanding the merit of any treatment or procedure advised by anyone, the same may in some instances justly be thought impracticable, though scientific. I have never been able to treat children satisfactorily by instrumentation. Though my idea is not in this paper to recite fully the non-operative treatment, I shall mention a few facts and ideas which can not be amiss.

The first of these is the surrounding sanitary conditions, for it is a well and generally conceded fact that heat and moisture and such environments as are unsanitary are predisposing causes of our endemic or sporadic dysentery. Therefore, particular care should be exercised in the selection and care of the bedchamber, as also the house and surrounding premises of one stricken with the disease, and directions given relative to the sanitation of these, and especial care taken in the disposition of the excreta of the patients.

All articles of diet should be selected with the greatest care and thoroughly cooked, if in the least liable to become contaminated with microorganisms. Milk, which in these cases is an article of diet almost indispensable, may be unfit for such use unless boiled. Soft boiled eggs, and especially the whites of eggs, given raw or beaten into froth and sprinkled over with lemon juice, is an article of diet which is the most serviceable and acceptable of all to the irritable stomach and bowel, and chiefly because it is digested in the stomach and leaves little residue. From six to eight eggs will be taken in this way during twenty-four hours without loathing.

In the early stages of the disease, there is usually noted extreme depression and the portal circulation is sluggish. The portal engorgement is first relieved, as also the intestinal tract is thoroughly freed of any indigestible and irritating ingesta by a large dose of salines, among which I prefer magnesium sulphate, to each dose of which may be added dilute sulphuric acid. For extreme depression and sluggish circulation, strychnin is indicated. Following this may be given such intestinal