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VOL. XXVI.

ST. LOUIS, MO., JUNE, 1898.

[Written for the MEDICAL BRIEF.]
Dysentery.

BY JOHN ANDERSON, M. D., F. R. C. P.,
Companion of the Indian Empire. Physician to the
Dreadnought Seamen's Hospital, Greenwich;
Lecturer on Diseases of Tropical Climates
at St. Mary's Hospital, London, Eng.
London, England.

Introductory.-Dysentery is universally defined as a specific disease-an inflammation dependent upon a specific cause. But is it a specific disorder in the true sense of that term? We are convinced of its specificity, but we possess no clear evidence that it is a disease originating from a single pathological cause which is invariably present, and which conforms to the condition held to be necessary to specificity. We may feel mentally convinced, but we have not yet discovered the bacteriological origin, or identity of origin of dysentery. On the contrary, the idea is very extensively held that the series of symptoms which we term dysentery very probably include several distinct diseases of independent but allied origin. Classification. - Whatever dysentery may be etiologically, it is certain that in the present state of our knowledge

No. 6.

we can but classify it symptomatically— some sort of classification must be adopted to enable us to grasp the characteristics of complex phenomena.

In the first place it will be necessary to divide dysentery into the acute and chronic forms, and the acute may be subdivided into simple and gangrenous. It may, perhaps, be justifiable to add amebic dysentery as a separate variety of the acute class.

Thus we have:
I.-ACUTE.

(a) Simple; catarrhal; ulcerous.
(b) Gangrenous.
II.-AMEBIC.

III. CHRONIC.

Adopting this course, we have now to describe the clinical features of the disease.

"Simple."-Simple acute dysentery usually commences with a griping diarrhea and a general sense of languor. There is a feeling of abdominal uneasiness and distention. The motions become more frequent and less copious as the hours pass. Tormina or colicky pains precede each evacuation. This often amounts to great torture, and at the termination of an unsatisfactory motion there is a violent straining or tenesmus

as it is called. These efforts, after a time, succeed in voiding little else than a gelatinous shreddy mucus tinged with blood, and the straining becomes so intense that it is difficult to induce the patient to rise from the commode and return to bed. An occasional scybala may be discharged with the earlier motions. These scanty sanguineomucoid stools possess a characteristic sickly, but not very powerful odor, which can never be mistaken-a foul, animal odor, without any traces of feculent smell, and totally distinct from the overpowering stench of a gangrenous dysenteric stool. There may be twenty, thirty, or many more of these minute motions in the twenty-four hours, each preceded by tormina and accompanied by tenesmus, so that the feeling of exhaustion soon becomes great. If these symptoms are allowed to persist for a couple of days, the bladder is apt to sympathize to such an extent as to cause dysuria, or even strangury, or retention of urine, especially when the inflammatory action expends its chief force upon the rectum; and the anus may become inflamed or prolapsus occur, thus adding much to the distress of the patient. Very often little separate dark clots of blood are attached to the stained mucus of which the stools consist. The tongue is coated, the urine scanty and high colored, and of abnormal density; the pulse is unaffected till exhaustion has progressed, when it becomes smaller and quicker; the skin tends to dryness, but when exhaustion has established itself, it becomes moist and clammy with each paroxysm of pain. There is no fever, or none of any consequence. The duration of such a case is not likely to be for more than a few days, a week at the outside, if properly treated; but if neglected, especially if mismanaged by the previous administration of astringents, it may progress to the gangrenous form of the malady, or gradually merge into the condition known as chronic dysentery.

"Gangrenous.” — - With this outlined picture before the mind, it is easy to conjecture the symptoms of gangrenous dysentery. Broadly speaking, they are the above plus the general symptoms which appertain to the gangrenous con

dition. You will already have noticed the absence of mention of general symptoms in simple dysentery, but now they assume a prominent place.

Either the simple form as described may lapse into the gangrenous, or the latter condition may commence directly with the case. In the former circumstances, all the symptoms become aggravated-the number of the motions, the tormina, the tenesmus, etc., but in the latter, the beginning is more insidious, the early diarrhea being less painful, though mucus and blood appear early, and the signs and symptoms of the gangrenous condition are not long in making their appearance.

When gangrene has set in, the character of the motions announces the event with certainty-the muddy, port wine colored liquid evacuations not unlike the juice which is squeezed from raw meat and containing shreds of mucus, small clots of blood, membranous fragments and minute black sloughs, are intensely and penetratingly offensive, possessing the peculiar cadaverous odor which, in itself, is perfectly diagnostic. Fleshy looking sloughs of the sub-mucosa, and even pus, are soon detected. A little feculent matter may be found on the surface of the dark red stinking fluid, while a quantity of dysenteric detritus of the nature stated, falls to the bottom of the vessel. For the purpose of inspecting this detritus, and thus estimating the amount of destructive mischief which has been accomplished, it will be necessary to "wash" the stools by adding water freely and roughly, so as to agitate the whole, allowing the heavier parts to subside for a few moments, and then slowly pouring off the upper liquid till it is observed that shreds are passing over the edge of the vessel. Then more water is added, and the process repeated till nothing is left behind but the threads of dead tissue, dark clots of blood, and a little clear water. The subsided material can then be examined at leisure.

Sometimes, though not very often, a considerable sized tubular slough, retaining the full caliber of the intestine, is voided per anum. Fayrer records a case during which one of these sloughs

a foot long, was evacuated. Formerly these ejected tubes were supposed to be membranous or diphtheritic casts of the gut, but a careful examination of their structure reveals them to consist of the altered and thickened mucous lining of the intestine.

The absence or presence of general symptoms is sufficient to differentiate between gangrenous and simple inflammatory or ulcerative dysentery. In the former we have great prostration which tends to progress to algidity so soon as the gangrenous process has become established, the temperature is subnormal, the pulse is fast and weak, debility is rapidly progressive, the general surface is clammy, and the sphincter eventually is relaxed.

"Amebic."-With regard to so-called amebic dysentery-as I have said, it is very questionable whether the amebæ of Lösch are agents responsible for the occurrence of any form of dysentery; but in the Johns Hopkins Hospital Reports published at Baltimore, in 1891, Councilman and Lafleur have argued the case so powerfully in favor of this distinct form that I feel it my duty to epitomize their views, always remembering that they are not accepted as fully proven. There is no doubt that in a certain number of dysentery postmortems we find, as I shall presently show you, cysts of the sub-mucosa filled with gelatinous colloid material, throughout the affected part, as the most noticeable morbid change. Councilman and Lafleur found that in these cases, the stools, the ulcers consequent upon the bursting of the cysts, and even abscesses of the liver, which frequently complicate these cases, teemed with amebæ; and injection experiments on animals tended to uphold their contention that the amebæ are the cause of this kind of dysentery, and of this alone. The late Dr. McConnell, of Calcutta, many years ago, described intestinal lesions similar to those mentioned by Councilman and Lafleur, but he attributed them to the earlier stage of ordinary dysentery. Councilman and Lafleur's observations led them to conclude that amebic dysentery runs a slow course, lasting from one to three months, without possessing any of the charac

teristics of chronic dysentery, though they admit it may merge into the latter. The stools are watery and contain mucus from the beginning, blood soon appearing. A marked peculiarity is the occurrence of intermissions at irregular intervals. There is no fever, or, at most, a little febrile disturbance. Death may result from exhaustion or ulceration unless some complication, such as liverabscess or hemorrhage, carries the patient off. Liver-abscess is said to be

a common result. Sometimes the cases run on to gangrene, and this event is notified as already explained.

"Chronic."-Chronic dysentery hardly needs description-you have, as a rule, thin, but not watery motions, of an earthy color, mixed with a good deal of mucus, blood appearing whenever there is an exacerbation from any cause, or without apparent cause. Month after month the case drags along, the sufferer emaciating the while. The tumefied and tender colon may be detected by palpation, and the iliac fossæ are painful on pressure. The clinical evidences of ulceration are apparent, and no difficulty can arise in recognizing a case.

Complications, Etc.-Though this disease has not intimate connection with malarial fevers, it may occur in subjects of the latter, and, no doubt, the debility and anemia of the malarial state greatly increase the liability to dysentery. The The two affections may, and do combine, under circumstances of exposure and fatigue in the tropics. But of all the complications of dysentery, or rather of all the conditions calculated to court and foster the most formidable and fatal kind of dysentery, the scorbutic taint is the worst and most to be dreaded. It is this scorbutic development in the jails of India, especially in those jails which are situated in unhealthy localities, which has contributed to their vast dysentery mortality. The tendency here, and under the privations of war and famine, is to a rapidly fatal gangrenous dysentery— indeed, the term "scorbutic dysentery" is well known and much dreaded.

Dysentery cases sometimes produce a general septicemia, when rigor and a febrile state are followed by a typhoid condition. Then, we may have paro

titis, swelling of the joints and peritonitis. Insanitary surroundings and overcrowding of large bodies of dysentery stricken people are calculated to yield a large percentage of such a type.

Multiple abscess of the liver is another recognized result of dysentery, though I rather think the statement has been exaggerated and more universally accepted than facts warrant.

Intestinal invagination is an occasional occurrence, especially when the cecum is largely involved. It declares itself by well-known symptoms-tympanitis, feculent vomiting, and collapse.

A very rare sequel of dysentery, but still an established one, is paralysis of the lower limbs, or sphincter ani, or tongue, but it usually gets well after the lapse of a little time.

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Mortality. The mortality from dysentery, in former times, was appalling, but this no longer is the case, unless under circumstances of exceptional privation. It is useless to attempt to compare former with present results, because we no longer have among us the fearful sea voyages when scurvy ravaged our navies, when the hygiene of jails and workhouses was utterly neglected, when armies were without an organized commissariat, when ventilation and air space were considered myths, when, in fact, all the factors which we now know to favor the development of this fatal disease were prevalent. I, therefore, shall not enter into any history of the olden time dysentery, painfully interesting as it is, but merely glance at present results now that we exert ourselves to remove the promulgating causes, and now that we know how to treat the disease. In the ten years, 1880 to 1891, we find that the deaths per mille of the strength of European troops in Bengal was only .60, while the admissions were twenty-six per thousand, and the percentage of deaths to total deaths, in 1891, was 2.6. Army statistics are particularly useful for our purpose, because all cases of disease are admitted into hospitals. The figures for the great civil hospitals of India show much less favorable results, because it is only the worst cases, generally in a neglected state of advanced illness, which seek admission; for in

stance, we find that 22.2 per cent of those treated for dysentery, died in the Medical College Hospital, Calcutta, in 1879. The jail population of India suffers severely - sometimes the mortality reaches an enormous figure, for example, Bryden shows that in the ten years, 1867-76, the death-rate in the unhealthily situated jails of Backergunge and Rungpore, in Bengal, no less than five hundred and forty-nine deaths out of one thousand from all causes, were caused by dysentery due to overcrowding, and a faulty and insufficient dietary.

Influences Affecting Dysentery.—There are various influences which affect dysentery in various ways, and to these I now invite attention. You will see what they have to do with the prophylaxis and management of the disease.

Elevated regions suffer less than lowlying, damp countries, and the season of the year has a well-marked influence, which, however, varies in different regions. Among English troops in India, August, September, and October are the months yielding the greatest number of cases; but our native army suffers most during the colder months-November, December, and January. In Europe the larger proportion occur in the summer and early autumn, and this is also the rule as regards America till we reach the Southern States, where we again find the tropical period asserting supremacy. There is no doubt, whatever, that exposure to the vicissitudes of climate, powerfully predispose to dysentery, and this is, perhaps, the chief reason why the ill-clad and ill-fed poorer natives of India suffer so much more in the cold than in the warm months of the year. The abuse of alcohol is another wellestablished predisposing cause. Instances of water contaminated with fecal matter as a cause of outbreaks are historical, both as regards armies and public institutions. Many interesting illustrations of these statements might be quoted, but time will permit me merely to enumerate them. Similarly, soil contaminated with fecal matter would seem to be a source, and in this connection Clouston's instance, published in 1865, of the outbreak in the Cumberland Asylum, owing to the immediate proximity of a sewage farm, is

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