There are few diseases in which a prudent employment of art is more useful, or in which early means of relief are more requisite than in this[114].
Where the dysentery is the original disease, and when the patient is robust and plethoric, with acute pain and a strong pulse, blood-letting may be practised with advantage in the beginning of the complaint. But there is no part of the practice in this disease in which the climate and manner of life makes a greater difference than in this; for in a temperate climate it frequently happens that repeated blood-letting is necessary; but in a hot climate, where the fibres are relaxed, and in the constitutions of seamen, whom we seldom or never find plethoric, the inflammatory symptoms requiring this evacuation do not run so high, nor continue so long.
It is in all cases of the utmost consequence to administer as early as possible a brisk saline purgative. An ounce and a half or two ounces of purging salts may be dissolved in a quart of barley water or water gruel, and given warm in cupfuls, at small intervals, till a free and copious evacuation is produced. If there should be much fever, or sickness at stomach, two grains of emetic tartar will be a great improvement of this medicine; and there will be this farther advantage from its use, that if the stomach should be loaded with bile, in which state it is more irritable, an evacuation upwards will also be excited to the great relief of the patient.
This early and seasonable measure will, in many cases, put a stop to the disease, especially if the patient is thrown into a sweat immediately after the bowels have been thus thoroughly evacuated. It is of great service in this disease to promote free perspiration, and even a plentiful sweat, which may be effected with great advantage by giving, at bed time, a medicine composed of opium, ipecacuana, and a little neutral salt, accompanying it with plentiful warm dilution. Nothing tends more to relieve griping and tenesmus than a general, warm moisture on the skin. The ipecacuana, which is an ingredient in this medicine, is one of the best anti-dysenteric remedies we know; the opium procures rest; and this, joined to the sudorific effect of the whole, not only gives a temporary relief, but tends to carry off the disease. It is most properly given in the evening; for there would be this inconvenience in constantly encouraging a sweat, that if the tenesmus should return, it would either be checked by the patient getting frequently out of bed, or there would be danger of his catching cold. I am well aware that we cannot be too cautious with regard to the use of opium in the beginning of this disease; but it is admissible more early in a hot climate than a cold one, as the inflammatory symptoms are less violent and can be sooner subdued; besides, it becomes an entirely different medicine when conjoined with the other ingredients that have been mentioned.
The best medicine in the day time we found to be small doses of ipecacuana alone twice or thrice a day; and if there should be fresh collections of bile, small doses of the saline purgative will be necessary. Ipecacuana in this intention, may be given in the dose of two grains in athletic constitutions, such as those of seamen; but in the more delicate constitutions, such as are commonly met with in private practice, one grain is a sufficient dose. I have found manna and tamarinds a good addition to this medicine in the earlier stages of the disease, where there was much bile; but in a more advanced stage of it they are apt to produce gripings and flatulence.
The marks of a redundance of bile are, a sickness at stomach, a sense of scalding at the anus when the stools are passing, and the yellow or green colour of the stools themselves. It is apt also to excite symptoms of fever, such as a foul tongue, a hot and dry skin, with thirst. When collections of it are suspected in this disease, it is best to evacuate it by vomiting, for it is thereby prevented from irritating the bowels, and from arriving at the inflamed parts with, perhaps, increased acrimony, acquired in passing through the whole length of the intestines.
Some gentlemen of the fleet informed me that they found oil of almonds a useful addition to the purgative. Others as well as myself made a practical comparison of the saline purgative with that composed of rhubarb and calomel, as recommended by Sir John Pringle, and we gave the preference to the former, as more easy, speedy, and effectual in its operation, especially in the first stage. Cases may occur, however, in which the other may be more advisable; for where there is a sense of weight about the stomach, which most probably arises from the biliary organs being clogged with bile, and where emetics have failed to remove it, or the weakness of the patient may render them improper, then calomel has the best effect: for it was formerly observed, that it tends to loosen the secretions, and to stimulate the more distant excretories, such as the biliary ducts.
It is very important to caution young practitioners concerning the employment of opium in all stages of this disease, but especially in the beginning; for though it is an excellent remedy when seasonably and judiciously employed, it is very liable to abuse, particularly in the hands of the inexperienced, who may be tempted to give it improperly from an anxiety to relieve; but as more harm may arise from an unseasonable administration of it than could be compensated by the best-timed use of it, it is best to err on the side of caution and omission. The principal caution to be observed with regard to this remedy is, to premise suitable evacuation, such as blood-letting, if necessary, but more especially purging. It is always pernicious to give it in its pure state during the tormina, so common in the first days. By these I mean the abdominal gripings, which denote inflammation, and are entirely different from the tenesmus, which is a more constant and characteristic symptom of the disease, and seems to arise from irritation and spasms of the rectum and colon.
It was in this disease that I first observed the good effects of a small quantity of neutral salt in taking off the inconveniencies attending opium, such as the feverish heat and confusion of the head, which it is apt to produce in many constitutions; and as the administration of the anodyne coincided with the evening dose of ipecacuana, I was led to adopt a form similar to that of Dover’s powder, but with only half the quantity of opium; or, it was given in a liquid form, by combining twenty drops of thebaic tincture and a drachm of ipecacuana wine, with nitre from five to ten grains, in any simple vehicle in form of a draught. There is a very observable difference, in some cases, between opium given in a liquid and in a solid form; and the former is much more certain in its effect when the intention is to procure speedy and effectual ease.
I have observed great benefit from the use of external remedies in dysentery, and these have, perhaps, been too much neglected by authors and practitioners. The warm bath is of great service, especially where the gripes and tenesmus are severe, and where the fever has been taken off by previous evacuation. Fomentations or warm applications of any kind to the abdomen give temporary relief; and it will be found of advantage to keep those parts, at all times, well defended from the cold air. Blisters to the abdomen were also found of use, and likewise acrid liniments, composed of oil, volatile spirits, and tincture of cantharides. Where the stomach has been much affected, I have perceived relief from fomenting it with stupes, upon which thebaic tincture and camphorated spirits were sprinkled, as recommended by Dr. Lind. I was once affected with a bad dysentery in the West Indies, and I thought myself much relieved by the warm bath and a blister. Strangury is not an uncommon symptom in this disease, independent of cantharides, and the most sensible and effectual relief is derived from fomentations to the pubis and perinæum, as I also experienced in my own case.