Treatment.—In the treatment of bacillary dysentery absolute rest in bed is important to keep up the strength of the patient and also to protect the heart which tends to be more or less damaged by the toxic action of the Shiga bacillus. Some prefer to prop up the patient in bed, considering a strict dorsal decubitus as undesirable. It is important to use sufficient covering on the patient to avoid chilling. A light wool blanket spread over the abdomen is often all that is needed in the tropics.
Some authorities deal with the subject of treatment without referring to any other means than the administration of serum. This probably is the proper attitude when the very fatal Shiga type infections are encountered. It must be remembered that certain epidemics, which as a rule are associated with the Shiga type bacillus, give a very high mortality (20 to 40%) while other epidemics seem associated with a less virulent strain of this bacillus.
At any rate when a case is seen early it would seem advisable to give about 2 grains of calomel in divided doses of ¼ grain every half hour and then follow it up with saline treatment. Most authorities recommend a preliminary dose of castor oil. During the first day or two enemata of normal saline, boric acid or 1½% sodium bicarbonate solution in 2 pint amounts would seem indicated as assisting the salines in the elimination of toxic material. After that time the tenesmus and rectal irritation make the use of the rectal tube too trying to the patient. I have used the Murphy protoclysis method with a certain degree of success, but this procedure cannot be kept up long. Hot fomentations to the belly relieve the griping pains.
The saline treatment is highly recommended by Buchanan who gives 60 grains of sodium sulphate every two or three hours until the dysenteric character of the stool disappears.
Bahr in the Fiji islands treated 53 consecutive cases, of which 41% had marked constitutional symptoms, with a mortality of 13.2%. He gave 1 dram of sodium sulphate every hour for the first day and subsequently the same dose every four hours.
In a second series of 106 cases, of which 42% had marked constitutional symptoms, he treated 34 with salines plus the administration of capsules of cyllin. The remaining 72 cases received in addition to this treatment injections of a polyvalent serum obtained from the Lister Institute. The mortality in this series was 1.8%. He notes that 5 of the cases in this second series were of the severest type as evidenced by the gangrenous stools and toxic condition and yet not one of these five serum-treated cases died. He notes that the stools of those who received serum injections became normal in five days for an average while for those treated with saline alone the average period was eight days.
Bahr strongly recommends the combined treatment of salines and serum. In very severe cases Bahr used 50 to 70 cc. of the serum but ordinarily 20 cc. for adults and 10 cc. or less for children.
Willmore and Savage think one obtains the best results by injecting from 80 to 120 cc. of a polyvalent serum into the subcutaneous tissues of the flank or abdomen or intravenously. They think that anaphylaxis is less liable to follow a massive initial dose of serum.