particular contribution to the debate should be as uniform as possible.

Transcription

1 AN EXPERIENCE IN THE USE OF EMETINE IN THE TREATMENT OF AMCEBIC DYSENTERY. V?y A. WHITMORE, M.D., CAPTAIN, I.M.S. Pthologist, G'enl. HosptlRngoon. [>* this short ccount results use emetine in tretment Amoebic Dysentery in this Hospitl, I propose mking use mteril in one block only Hospitl wrds. I do this becuse 1 believe tht in ny discussion upon vlue recent method tretment it is dvisble to ensure tht conditions prticulr contribution to debte should be s uniform s possible. \j

2 Mrch, 1914.] WHITMORE ON EMETINE IN DYSENTERY. 113 (this course mens wshing ; diluted fecl mtter being slowly poured out over white porcelin sink)? stools pper to be norml, st stools, sve perhps for some undigested food We hve not dopted s routine mteril. mesure dily exmintion for moebe. In view occurrence relpses I expect tht creful miscroscopic check would be useful s guide to suspension energetic use emetine, but for this our lbortory stff is too smll. cses cute 34 In mjority our nd stools hve cesed, dysenteric symptoms ssumed norml chrcter fter 4, or t most 5, dys hypodermic emetine tretment. hospitl. During lst nine months I hve dopted For rest ir sty in hospitl subcutneous injections emetine s routine ptients re given smll doses (grins x?xv) Pulv. ipecc, twice or three times dy, tretment those suffering from moebic s unless s soon hs been tretment for some or disese such s dysentery, dignosis mlri is required. estblished. In mjority cses re lis been no difficulty in rriving t dignosis within Until quite recently this emetine tretment hs hd surprisingly rpid nd certin effects 36 hours ptient's dmission to hospitl : in first plce, dignosis depends upon which Lt.-Colonel Rogers hs stted to hve been history illness, generl condition his experience use drug. Among ptient, nd chrcter stools. I should 34 cses we hve hd 4 deths ; bub se like to suggest tht in cses seen within first deths do not detrct from my high opinion six d}ts onset intestinl disese efficcy drug. In one cse with symptoms correct dignosis cn generlly be mde upon this who been dmitted hd ptient, A good del is gngrenous dysentery, hd been dischrgclinicl exmintion lone. written upon difficulties clinicl dig- ed quite free from dysenteric symptoms nd nosis dysentery : during lst few yers I rpidly convlescing fter few weeks' sty in hospitl nd 10 dys' emetine tretment. hve been constntly deling with cses lrge bowel inflmmtion, dignosis hve been Three weeks fter his dischrge he returned to regulrly checked by reference to neighbour- hospitl in n emcited condition, hving been ing lbortory, nd I hve come to conclusion deserted by his friends. He died generl tht once fir experience fecl exmintion debility six weeks lter, nd t post-mortem in wrds hs been cquired, it is rre indeed exmintion his lrge bowel ws found to be tht correct dignosis moebic dysentery much scrred, due to heled, lrge, dysenteric cnnot be mde upon clinicl exmintion lone, ulcers ; nd in lowest third to be set if cse is seen within first week erly terminl bcillry dysentery. His extenillness. If deprived microscope, I would hve sive moebic dysentery hd been entirely cured much more confidence in my speedy clinicl by 10 dys' tretment with emetine. A second cse died 12 dys fter dmission. dignosis moebic dysentery, thn I would in tht mlril infection. It is in ltter The ptient ws n old mn, ged bout G5 yers. stges moebic dysentery, when symptoms He hd been dmitted to hospitl for generl hve become those chronic dirrhoe, tht debility, with scites nd generl nsrc some clinicl dignosis becomes difficult, nd creful two months' durtion. His stools were observed to be microscopic exmintion essentil. dysenteric, nd continued moeb; However, in ll cses which hve been histolytic. After 6 dys' emetine tretment his treted with emetine dignosis hs been con- dysenteric symptoms hd subsided, but he died firmed by miscroscopic exmintion. It is our 12 dys fter his dmission to hospitl. At experience tht in untreted cses, if fresh stools post-mortem exmintion his lrge bowel ws re secured, this microscopic exmintion is found to hve severl very lrge dysenteric ulcers, lmost s esy, nd s stisfctory, s tht but se were ll clen, nd showed signs blood mlril cses for mlri prsites. rpid heling. In 34 cses with which this note dels, The third cse ws n old Mhomedn, ged tretment dopted hs been injection eme- bout 70 yers, dmitted for fever nd cough tine, generlly in b grin doses twice dy, until bout 14 dys' durtion. He ws found to stools re reduced in frequency to 2 or 3 in hve lrge liver bscess, in pus which 24 hours, nd re free from mucus nd blood; moebe were esily found. The bscess ws so tht drined closed exmintion? by dringe, nd emetine upon creful microscopic The wrds with which I m concerned probbto certin extent with wrds in Clcutt in which, under direction Lieut.Colonel Eogers, utility drug ws first stisfctory demonstrted. For y re within very short distnce Lbortory, nd re under direct control Pthologist; so tht fcilities for lbortory dignosis re vilble. nd generl spirit wrds fvours n ttempt t exct dignosis. However, ptients re generlly puper, friendless ntives Indi, so tht from point view physique nd generl nourishment }* constitute most unfvourble clss ptients ny in ly correspond

3 THE INDIAN MEDICAL GAZETTE, 114 temperture previously 101? fell to norml immeditely, nd remined norml, bt old mn grdully becme weker, nd died G dys fter dmission to hospitl. A post-mortem exmintion ws not obtined. The fourth ftl ese ws tht Hindu mle, ge 20, who ws dmitted to hospitl very seriously ill. He ws very nemic, ill-nourished mn who hd been engged in coolie work in jungle, nd for lst four months hd been out work owing to ill-helth. He ws exws found to be sufferdebilitted nd ; tremely from ctive nd cute moebic mlri ing dysentery. After 5 dys' emetine tretment his dysenteric symptoms hd cesed : fter 7 dys' tretment -i- grin twice dily emetine ws stopped, but 3 dys lter dysenteric symptoms returned nd emetine ws gin dministered. He seemed to be doing well, but died quite suddenly in erly morning fter 15 dys in hospitl. There ws no post-mortem. but I believe tht he died during n cute ttck mlri nd not from his dysenteric infection, which, judging from clinicl signs, hd been controlled. Until lst six weeks my experience hd been tht emetine, dministered in -i grin doses twice dy, very rpidly checked ll clinicl signs inoibic dysentery, nd I ws very strongly opinion tht in emetine we hd s certin for moebic infection s in cure we hve certin remedy for mlri. quinine But just s in mlri relpses re not unusul, so in dysentery, treted with emetine, relpses hve not been rre mong ptients in my wrds. Among 25 ptients we hve hd 5 relpses. The following will serve s chrcteristic exmple relpse some little time fter t he cesstion ll cute symptoms :?A modertely nourished Hindu, mle, ge 45 yers, dmitted for dysenteric symptoms one month's durtion ; stools contined moebic histolytic? nd temperture upon dmission ws 102. After 5 dys' tretment with ^ grin emetine hypodermic-lly twice dy, ptient ws considered convlescent, nd ws free lrom dysenteric symptoms, but 1G dys lter se symptoms returned, nd fter course Pulv: ipecc: dministered; lsting 14 dys prently well. ptient ws dischrged p- The or cses relpse were very similr to nd with view to prevent relpse ptients re now plced ipecc fter upon smll doses preliminry 5 to 7 dys' emetine tretment. It is too erly to determine wher or no continution mild course ipecc fter dysenteric symptoms hve cesed is this, vlue or not. With occurrence o( re use ol emetine s lpses, my for moebic dysentery hd been entirely remedy exception experience stisfctory, end until [Mrch, some six weeks go About December, nd beginning 7 O o receive t hospitl number re returning from nnul pddy hrvest. These ptients re usully very poorly nourished, nd hve been sick ten for month or more before rriving t hospitl; y re suffering from multiplicity ilments, generlly mlri combined with dirrhoe or dysentery. >Six such ptients dmitted to my wrds were dignosed moebic dysentery nd treted with emetine. This tretment hs been pprently unsuccessful, so much so tht I doubted efficcy brnd emetine which we were n using. The drug ws preprtion by wellknown nd relible firm chemists, nd Chemicl Exminer reported tht smple conformed to ll usul tests for emetine. As our dignoses hd been mde crefully, nd re seemed no reson to doubt ir ccurcy, I could form no or hyposis thn this n inefficient preprtion drug, nd ccordingly pplied for supply different mnufcture. However, before this lis been received three ptients hve died, nd jjost-morterit exmintions re certinly helpful in elucidting pprent filure emetine tretment. I give very briefly illnesses nd post-mortem findings se three ptients. 1. A Hindu, ge bout GO, poorly nourished, dmitted for dysenteric symptoms some 3 weeks' durtion. The stools were firly chrcteristic moebic infection, nd moebe histolytic were reported s present. Emetine, grin -i- bis die, ws given hypodermic-lly, nd fter 3 dys stools hd improved, but y contined much mucus in which moebe were still found. The emetine ws incresed by i grin dily, but fter 7v> grins hd been dministered our supply fell short, nd ipecc, by mouth ws substituted, toger with bowel wsh-outs dilute A', ipecc. The stools did not improve nd t end three weeks few smll inctive moebe were reported to be present still in stools, nd dignosis moebic dysentery ws mintined. A second course emetine 5 dys' durtion ws tried, but dirrhoe with blood nd mucus in stools continued. The ptient died bout week lter nd t post-mortem exmintion lower hlf lrge bowel ws found to be set ctive subcute ulcertive colitis, not moebic (no moeb} could be found in scrpings nor were lesions those chrcteristic moebic infection) ; in upper portion lrge bowel were severl lrge rditing scrs such s we hve been in hbit ttributing to heled moebic ulcers. I m quite confident tht this ptient did not die moebic infection, but I believe tht our initil dignosis ws quite correct, though it overlooked possibility more chronic Jnury, we ptients who \ f(\

4 L WHITMOEE ON EMETINE IN DYSENTERY. Mrch, bowel ulcertion complicting moebic ulcer tion. The finding smll inctive moebe in stools would hve gone for nothing in preliminry exmintion, but dignosis moebic dysentery hving once been mde, nd looked upon s certin, we did not question tht se moebe found lter on were pthogenic vriety ; so fr s I m wre we did not endevour to do more thn note presence or bsence moebe. A Hindu, mle, dmitted bout sme 2. time s lst cse. Dignosis moebic dysentery mde upon both clinicl nd microscopic exmintion. Emetine i grin twice dy ws dministered for 5 dys nd seemed to be successful; stools, from 11 or more in 24 hours, hd become 3, nd were prcticlly On Otli dy temperture rose norml. nd dirrhoe returned. The temperture remined irregulr, nd blood nd mucus gin The lbortory filed to returned to stools. demonstrte moebe, but s dignosis hd been so certin, nd stools were gin so obviously dysenteric, no gret importnce ws negtive finding, nd emetine ws gin given : 5 grins were given without ny effect, nd s t this time suspicions hd been roused tht preprtion drug ws fulty it ws suspended nd Pulv: ipecc: given, ttched to this but without benefit. About week lter ptient died, nd chrcteristic cute lesions bcillry dysentery were found in both smll nd lrge bowel, nd lso scrs recent moebic The exct bcillry ulcers in lrge bowel. infection hs not yet been worked out. I hve not lest doubt but tht this ptient hd moebic dysentery when dmitted, nd tht this cured by his first course emetine. His bcillry infection ws cliniclly distinct, nd ws perhps contrcted in hospitl ; but bised s we were by preliminry dignoses, we were unble nd unwilling to ttch significnce to signs which ought to hve led to correct Ms dignosis. 3. A Hindu, mle, ge 30, very ill-nourished, nnd very seriously ill with dysenteric symptoms : s before dignosis moebic dysentery ws mde nd seemed certin. Treted with emetine he improved,but did not mke strt!ingly rpid recovery usul in moebic infections. After 7j grins emetine his stools were fecl, but mucus ws still present in firly lrge quntities nd his disese ppered still ctive. However, lbortory exmintion now gve n uncertin upon clinicl signs tht I relied tht ctive dysentery ws still furr more present. Lter prolonged emetine bourse ws tried, but 13^ grins 'dthougli ptient ws slowly improving, his stools were sftill frequent nd contined mucus. Ife decided to leve hospitl nd return to his result, m nd it ws determining 115 A week lter lie ws picked up ded friends. At post-mortem close to hospitl. exmintion it ws found tht dysenteric ulcers were heled, but y hd been extremely extensive, so tht in mny plces only smll islets mucus membrne hd been left, nd se were (edemtous nd unhelthy, but not ulcerted; moeb? were not demonstrble. The explntion cse ws cler : originl dysenteric ulcertion hd been so extensive tht fter ll moebic ctivity hd cesed restortion proper formtion ws impossible, t ny rte, prt from tedious nd prolonged convlescence, nd lthough clinicl symptoms pssed from those ctue moebic dysentery to those chronic, it to conclude tht se chronic, or ws inccurte subcute, symptoms were due to continued presence living moeb?, i.e.. tht emetine hd filed to cure moebic infection. Spce forbids tht I should furr discuss this experience emetine tretment t ny length : but it seems to me. tht in ny discussion upon efficcy new remedy it is highest importnce to exmine very crefully ll pprent filures. For, if drug be successful t ll, re is n irresistible tendency to exlt unduly its successes nd to be blind to its filures. However, though t first sight I thought it certin tht se prticulr cses were cler exmples filure Emetine tretment? for in ll correctness dignosis upon dmission ws supported by good nd sufficient evidence?yet 1 m now stisfied tht, so fr from being exmples filure emetine, y re striking evidence to contrry. Insted ttributing non-recovery se ptients to some fult in drug, s t first I ws inclined to do. post-mortem findings compel me to dmit tht explntion lies in I think tht this dignosis my fulty dignosis. were ws correct in sense tht se ptients suffering from n moebic infection, but such ws From firly but prt only ir ilments. wide experience in mortury work I m well wre common complexity bowel infections strved, neglected, ntive ptients, but mong it is difficult lwys to keep this knowledge iji mind in mking clinicl dignosis. ^Moreover, in lbortory work it is not esy to free one's mind from bis first stisfctory exmintion, when exmining mteril for second or If t first exmintion third time. undoubted moeb? histolytic? mteril fsecl hve been found, it is not unnturl tht t subsequent exmintions flse importnce should be ttched to presence inctive forms moebe doubtful species ; nd unfortuntely in mny cses lrge bowel disese thn moeb? histolytic? re moeb) or re nd probbly no prticulr present, I believe tht n experienced significnce.

5 116 THE INDIAN MEDICAL GAZETTE. lbortory worker cn distinguish such moebe, but considerble cre is lwys necessry. At ny rte, wher my preliminry dignosis in se cses ws correct, or not, cses mselves re interesting ; for, prt from evidence furnished by post-mortem exmintions, y would hve been quoted s filures Emetine tretment, nd it seems to me tht upon pper t ll events evidence tht filure would hve been prticulrly strong. Y [Mrch, 1914.