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CHAPTER XXII.

Local Medication.

The direct application of germicide remedies to the inflamed and ulcerated intestine is of special importance in the chronic stages of amoebic dysentery. Indolent sores and putrid centres of toxin formation are frequently restored to healthy action by means of rectal injections after all other methods of treatment have failed; and the specific micro-organisms—on which the persistence of the disease depends—are more effectively destroyed in this way than by any other form of medication.

Doubts have been expressed as to the utility of germicide douches on the ground that anatomical and physical conditions make it impossible for rectal injections to reach the seat of disease in the colon, and that, in any case, these solutions cannot possibly affect entamoebae which are developing in the sub-mucosa and the deeper tissues of the intestinal wall. But it has been repeatedly shown by skiagrams, and in many other ways, that local applications properly introduced encounter no serious obstacle until they arrive at the ileo-caecal valve; and practical results abundantly attest their efficacy and value. No therapeutical tact is more fully confirmed than that deeply-seated organisms may be destroyed by flushing the colon with suitable germicides, and that direct medication is the most rapid and effective method of dealing with protracted and obstinate amoebic infections.

The local treatment of chronic amoebic dysentery generally necessitates the administration of at least ten or twelve intestinal douches—one or two being given daily—and as during this period the diet must be carefully regulated, and the bowel prepared for the reception of each injection, the patient should, if possible, be placed in a nursing home. To a great extent success is dependent on efficiency of method and technique; and the best results can only be attained when continuous attention is given to the details of treatment.

Practice, moreover, must be regulated by the general condition. In most cases absolute rest in bed is unnecessary, and a certain amount of movement and distraction is desirable. After irrigation the patient may sit up in an easy chair, or move about from room to room. In exceptionally mild cases, germicide douches may be employed without interference with the usual occupations, but active movement or exertion, except in the intervals of local treatment, should be forbidden. Absolute rules for this as for other details of treatment are, however, undesirable, and each case should be treated on its own merits.

The introduction of a germicide solution is best effected by means of a soft but substantial rubber tube, one and a half to two yards in length, attached to a glass reservoir of two quarts capacity, from which, solely by force of gravity, fluid may flow freely and steadily into the intestine. On account of their tendency to excite peristalsis, Higginson's and other forms of pump syringe are unsuitable; funnels are apt to admit air; and rubber reservoirs decompose and are difficult to keep clean. The rectal portion of the tube, although flexible, must be sufficiently rigid to keep a direct course to the upper curve of the sigmoid flexure under the gentle force which is necessary to overcome the obstruction offered by an infiltrated and often constricted passage; the nozzle should be rounded, with only one opening at the extreme tip; and the body of the tube should be perfectly smooth, of uniform calibre, and not more than five-eighths of an inch in diameter.

Suitable irrigation tubes are difficult to obtain, and although a serviceable appliance may be fitted up by connecting a soft rubber pipe to a stomach tube, a special apparatus is desirable. An intestinal irrigator has been constructed for me by Messrs. Allen and Hanbury which has the following advantages: It can be thoroughly and rapidly sterilized; the distal end is hardened and slightly contracted, so that if it becomes clogged with mucus or other matter, it may be readily cleared by a little manipulation and compression of the tube; it cannot kink or turn back in the bowel; and the flow of fluid into the intestine may be accurately observed and regulated.

Before the administration of a germicide injection the lower intestine should be washed out by a preliminary douche of 50 or .60 oz. of warm water, or a weak solution of boric acid (1 gr. to the ounce). For cleansing purposes mucilaginous vegetable infusions, such as linseed, are unsuitable; and as soap, bicarbonate of soda and other alkalines may counteract subsequent acidity they should also be avoided.

While an injection is being administered the relations of the rectum to the other abdominal viscera are important. The pelvis should be raised on a hard pillow 8 or 10 in. above the level of the bed, and the patient should be placed across the elevation in the left prone position; that is to say, he should lie on the left side with the right thigh flexed on the abdomen, and the face and chest turned down to the mattress. In this attitude the highest part of the colon—the splenic flexure—will be 5 or 6 in., and the lowest— the hepatic flexure—8 or 9 in. below the sigmo-rectal junction. The tube, well lubricated with unmedicated vaseline, is then carefully introduced as far as it will go without undue pressure, and 30 or 40 oz. of solution, warmed to 960—98°, are allowed to flow steadily into the bowel. During the operation the patient must keep perfectly still, and the same position should be maintained for five minutes after the injection.

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Given in this way, a remedial application readily penetrates to all parts of the colon, and is usually retained without difficulty; whereas, if the patient is rolled or swayed about, as is often recommended, spasm and the accumulation of flatus are generally induced, and the desire to evacuate the injection becomes uncontrollable.

Although the left prone attitude is generally preferred, many physicians advocate the dorsal or the knee-elbow positions, and provided the pelvis is well raised they are almost equally satisfactory. In cases where the intestinal reflexes are abnormally excitable and the mucosa hyper-sensitive, rectal irritability may be overcome by raising the end of the bed 18 in., or if that is ineffective by placing the patient in the Trendelenburg position; but in ordinary circumstances these proceedings are unnecessary.

Flatulent accumulations in the alimentary tract are by far the most frequent cause of intolerance of injections. If they are not brought away by the preliminary douche, intestinal gases may sometimes be successfully expelled by abdominal massage, or by giving a second douche of normal saline solution containing 20 m. of liquor opii sedativus before the injection. In cases of persistent fermentation and irritability, Pil. asafoetidae co. is a useful and reliable remedy. The rectal tube and connection should be freed from air before introduction.

Even when every precaution is observed, a certain amount of reflex spasm is almost invariably excited by the inflow of fluid. In some instances a rapid stream seems to be less irritant than a slow trickle; in others, only complete cessation can avert immediate expulsion of the injection. In such circumstances the conditions best suited to each case must be determined by changes in manipulation, in the strength and temperature of the injection, or in the position of the patient. Tuttle states that he treated amoebic dysentery successfully and with almost complete freedom from discomfort or spasm by large enemas of ice-water; and as he had previously claimed that cold—which affects free-living amoebae scarcely at all—was fatal to parasitic forms he believed that the germicide action was a result of the low temperature. MusGRAVE, Harris and others who agree to the soothing effects of cold, have, however, shown that frozen dysenteric dejecta, when thawed and injected into cats, still induce true amoebic dysentery.

There is, moreover, great variation in capacity to tolerate large quantities of fluid. Most patients are able to retain three pints, but four or even more are frequently introduced without causing the slightest inconvenience. The female abdomen is, naturally, more tolerant than the male. The point is of some importance, for the local medication of chronic amoebic dysentery can be satisfactorily carried out only by copious quantities of fluid, and it should be an invariable rule of practice to make injections as large as they can be borne.

Numerous experiments have been undertaken to test the exact germicide values of different preparations, but in vitro results are by no means reliable guides to treatment, and clinical experience indicates that the selection of a remedy presents fewer difficulties and is of less practical importance than efficiency of technique and method in administration. Provided it is an active germicide, constitutionally innocuous and properly administered, success may be attained by almost any one of a large number of drugs; but, in practice, solutions of the salts of silver and of quinine are generally regarded as the most useful preparations.

Silver compounds.—On account of their unirritating effects the

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