Clinical Cases

Bacillary Dysentery in a Young Child

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Preliminary data :
Miss : D.D. ; Female, 8 years; Hindu; Lower-Socio Economic Status ; Living in slum nearby; Mother : Divorcee, staying with her daughter;
Date: 19-10-96

Acute History
Child complained of loose unformed stools with mucus+ in large quantity and frank blood in stools since last 3 days. Stool was also offensive. She complained of severe colicky abdominal pain of griping type all over. Intensity of pain was so much that child expressed her agony “As if she will die” due to pain. She was better only by doubling herself. She was in constant distress, as she had frequent urge to pass stool. In one day she would pass around 20-25 stools of scanty to moderate bulk. She also passed involuntary stool once.

She also had moderate to high grade fever with chilliness rigors since last 2 days. There was a constant nausea. Nothing could be retained due to nausea, and appetite was low. Due to poor intake and the stress of the illness, child was tremendously weak (so much so that she could not raise her hand up while talking to physician and in waiting room). She climbed down on the bench.

Personal History- Thirst was low due to nausea during rigors and chilliness; she desired covering. Urine -Yellow, No H / O Oliguria No H / O. Dysuria Appetite: Low.

Past History
No significant past history. No such similar complaints in the past.

Examination:

Temp: 99.4 degree F Pulse- 100 / min Regular, Volume Low, All peripheral pulses felt,
B.P. : 110 / 70 mm Hg
Tongue: Moist with thick white coating, Pallor+: No Icterus, No Lymphadenopathy, Conjunctiva: Moist, Skin texture: No signs of dehydration;
Pharynx: NAD; Per Abdomen: Abdomino thoracic respiration, guarding in umbilical and both hypochondria, relieved after re-enforcement, no rigidity. Tenderness, all over especially in umbilical region and hypochondrium;
Liver degree / Spleen degree / Kidney degree Tympanic note, Peristalsis+.
Respiratory system: NAD.
CVS: S1 S2 Normal heart sounds. CNS: Conscious fully oriented / Speech (No) / Pupils BERIL.

Investigations:
We wanted to do CBC, Routine stool and microscopic, SOS, Serum / electrolyte, Stool-Culture and rectal Swab, but as patient could not afford it she could only manage to get routine stool done.

STOOL REPORT:
Appearance : Reddish Yellow
Consistency : Liquid
Pus Cell : 55-60 / HP.F
PBC : 10-12 / HP.F
Occult Blood: positive
Mucus : ++

Provisional Diagnosis: Bacillary Dysentery

Observation:
The attending physician noticed that the child faltered for a few moments while describing her sleep. From that point onwards the physician decided to explore the sleep in detail. He received some more information about this that had started along with this illness. She has been getting up startled from sleep, then gazing at the door smiling to herself and going back to sleep again. After gaining the child’s confidence she described her dream which was occurring repeatedly. She saw a man hiding on the side of the door, waiting for her to come out. Then he grabbed her and pulled her to a lonely place and stabbed her to death with a knife. At the end of the dream she gets up terrified full of fear.
Mother had confirmed that her child has been starting from sleep. In fact this has been happening for last 6 months, especially when child had fevers.

Emergency Totality and Management:
We advised that the child be admitted. The mother refused as she had severe financial difficulties and would not be able to bear the cost of admission. In addition, she had to go for work to earn her livelihood.

Totality:
o The expression of psyche in a somatic infective illness, i.e. infective biological causative factor
o Fear of murder or being assassinated (ref. phatak)
o Sensation of pain and its intensity (colicky) >+++ doubling up
o Pathology of acute inflammation, with possible ulceration, toxicity of colon (ref. Hering)

This dream expresses the child’s subconscious fears, the fear of her own death through murder or rather through a planned murder like an assassination. The subconscious of the child was expressing itself in periods of stress such as during fevers. The pace of the disease was moderate, reactivity active and vitality was good as indicated by high fever with rigors and frequent urging for stool. Hence susceptibility is moderate to high. Miasmatic expression is tubercular; classified as an acute infective illness.

RX: “Plumbum metallicum” was prescribed in 200th Dilution 4 pills to be taken qds.

Ancillary Measures:
Child was strictly advised to take plenty of oral fluids, curds and buttermilk and report immediately in ER if not better in 8-12 hours.

Follow up:
One hour after the first dose, the child for the first time in 3 days asked for the food and was able to retain it. The fever slowly settled. Sleep improved a lot and the child stopped getting up throughout the night. The frequent urgings and loose stools continued for the next 8 hours.

In next 24 hours child passed only 4 stools and less blood and less mucus. The intensity of pain has reduced considerably and so has the frequency.

After 26 hours of 1st dose child passed only one semisolid stool with no frank blood and scanty mucus. Sleep and appetite improved, her general state was much better thereafter.

Chronic Management:
To build the state of susceptibility, child was put on a regular constitutional medicine to prevent relapse of illness and preventing it from assuming a chronic dimension. Child has been reporting till date, but has not reported any recurrence of complaints.

Thus we see here a state of susceptibility under constant strain which allowed the disease to make inroads and express itself from the simpler mode of dreams, to a dreaded ulcerative inflammatory pathology of bacillary dysentery.

This case also highlights the importance of mental concomitants in physical illness which presents itself in acute forms. It leads us to a greater conceptual depth of acute illness and opens up a new facet of thinking to apply in practice.
Discussion DC28:

This case demonstrates a phase of this child’s life that started expressing itself six months ago through her subconscious. The peculiar dreams indicated the fears she had subconsciously, but only when under stress, mainly during fevers. Most of them indicated good vitality, where temperature was not high enough for child to be delirious. These early indications went unattended and finally culminated in a full- blown pathology of a destructive type threatening the child’s life.

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Dr. Hitesh Shah, BHMS (Bom)
Dr. Navin Pawaskar, MD (Hom)
Director, Clinical services,
ML Dhawle Trust and Organizations

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Hitesh Shah

Hitesh Shah

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