Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 16)

²¹ Thèse de Paris, No. 39, 1836.

²² Recherches cliniques et anatomiques sur les Affections pseudo-membraneuse, Paris, 1861.

Whitehead, in summing up his conclusions respecting the nature of the disease, compares it with dermic inflammation. He says: "The mucous membrane (intestinal), like the skin (and is not the one looked upon as an inversion of the other?), is prone under certain conditions in certain constitutions to develop products unnatural to its functions. It is not natural for the skin to produce eczema, neither is it natural for mucous surfaces to produce mucus in a concrete form; that the proximate cause of the symptoms referable to this disease is the hypersecretion and accumulation of mucus on the free surface of mucous membranes; such accumulations sheathe and prevent the healthy performance of the functions natural to the part, and thus induce immediate and remote results, the effect of such suppressed functions; that this hypersecretion indicates a want of balance between nerve-force and germinal matter, and that the nerve-force is perverted by irritation."

Simpson held similar views, and regarded the disease as a chronic pellicular or eruptive inflammation of the mucous lining of the bowels.²³ Other observers have been inclined to ignore the inflammatory nature of the disease, at least as a primary condition, and have sought the proximate cause in some as yet undefined derangement of the nervous system. Thus, Clark does not regard the membranous exudates as the products of inflammation, properly so called—that is, of capillary blood-stasis which has preceded their formation—as the characteristic of such exudates is that they contain fibrin. He says the abnormal cell-forms present arise in some other way than by free cell-development out of an exuded blastema. Good²⁴ asserts its dependence upon what he calls a "peculiar irritability of the villous membranes of the large intestines, which in consequence secrete an effusion of coagulating fibrin—fibrin mixed with albumen—instead of secreting mucus, occasionally accompanied with some degree of chronic inflammation."

²³ Obstet. Works, Am. ed., p. 279.

²⁴ Study of Medicine, op. cit.

Also, DaCosta doubts whether the disease is originally inflammatory at all. "Where inflammation," he says, "occurs, is it not secondary rather than primary, the result rather than the cause?" "Is not the true trouble in the nervous system, in the nerves presiding over secretion and nutrition in the abdominal viscera?"

Bennett and Byford represent the opinions of a very small minority who regard the disease as simply an expression of uterine derangement.

MORBID ANATOMY.—As none of the cases coming under my observation terminated fatally, no opportunity was offered to me of making personal investigation into the anatomical changes occurring in membranous enteritis. Such opportunities have been so rarely met with that, indeed, it may be said that the nature of these changes is wholly unknown.

Simpson alludes to a case of phthisis in which the patient had passed large quantities of "membranous crusts or tubes," and in which the mucous membrane of the colon was covered with an immense number of small spots of a clear white color, or vesicles, which, when punctured, discharged a small quantity of clear fluid; and also refers to the case of Wright, in which the mucous membrane of the colon and of the lower portion of the small intestine was studded everywhere with a thickly-set papular eruption.

My endoscopic examinations revealed, in the living subject, the intestinal mucous membrane of a red, verging into a scarlet color, thickened, and denuded of epithelium in patches of varying extent. This condition does not always invade the ampulla of the rectum, but with the long tube I am in the habit of using it was possible in all my cases to reach a point where it existed. The extent of diseased surface can only be conjectured by an inspection of the exudates and by abdominal palpation.

In most cases the exudate is restricted to the large intestines—colon and rectum—and often to a circumscribed portion of them; but in rare cases its length and quantity would seem to indicate that extensive portions of the surface are covered. One of the most remarkable cases recorded is that of a woman forty years old who had been sick for five years with gastro-intestinal derangement. Suddenly the case became acute, and after much suffering she passed membranous exudates three millimeters in thickness and many centimeters long, weighing in all three kilograms.²⁵

²⁵ Recueil de Mémoires de Médecine, de Chirurgie, et de Pharmacie militaires, tome xxxvii. p. 297, 1855.

Kaempf²⁶ gives another case, in which the length of the membranes discharged was sevenfold greater than the stature of the patient. In Dunhill's²⁷ case the patient had suffered from this disease for a long period, and during two years passed many yards of perfect cylindrical shape, many of them several feet in length, and sufficiently coherent to permit of their being handled, held up, etc. In one of my cases a perfect cylinder three-quarters of a yard long was voided.

²⁶ Op. cit., p. 232.

²⁷ Trans. of Path. Society of London, vol. ix. p. 188.

Laboulbène²⁸ describes the gastro-intestinal false membrane as thin, soft, and granular, of a more or less yellow color, slightly adherent to the mucous membrane, and when stripped off forming a yellow pultaceous mass. He says it is first deposited in small, irregular, sparsely-scattered patches, located on the summits of the intestinal folds; afterward these patches increase, and cover the folds entirely and almost the whole calibre of the intestinal canal. The mucous membrane, he remarks, beneath the deposit is greatly inflamed.

²⁸ Op. cit., p. 105.

Powell believes that at times the deposit extends as high as the duodenum, his opinion being solely based upon the clinical features of the disease. In the first of his cases the membrane was found in perfect tubes, some of them full half a yard in length, and certainly sufficient in quantity, he says, to have lined the whole intestinal canal.

In examining the membranes it is always best to float them from the fecal or other foreign material by passing the discharges in a clean vessel containing water. Their physical characters can then be readily studied. They are best preserved in a 10 per cent. solution of alcohol. The exudate consists usually of a single lamina, but at various points in certain cases several superposed laminæ may be observed, enclosing between them particles of undigested food of various kinds. In most cases the superficial layers are more opaque, drier, less elastic, and friable than the deeper.

The configuration of the exudate varies greatly. The more common variety is that occurring in loose, transparent, jelly-like masses, like the white of an egg or glue, tinged often with various hues of yellow. In three of my cases I noticed also the frequent occurrence of a thin, serous, yellow discharge. In some cases the discharge resembles pieces of macaroni, tallow, or wax; in others it assumes a shreddy or ribbon-like form; and in a still rarer class it is tubular, being an exact reprint of the surfaces from which detached. These tubular pieces are, however, more or less torn and broken into smaller fragments of an inch or two in length when discharged.

Its thickness also varies: sometimes it does not exceed that of the thinnest film, and at others it is a quarter of an inch or more.

Its consistence ranges from that degree of loose aggregation that permits elongation into stringy, breaking masses when fished up from the water in which it floats, to a firmness and tenacity that will enable it to be handled without fear of breakage.

The color differs in different cases. It is usually yellowish-white, but this is often modified by tints dependent upon admixture with extraneous matters from the intestinal canal—biliary coloring, blood from the rupture of the vessels beneath the exudate, or with blood and pus. It exhales a feculent odor.

The surfaces of the membranes are ordinarily smooth and uniform, but sometimes reticulated. Certain observers have described the outer surface of the tubular exudate as uniformly smooth, and the inner as broken and flaky at some points, at others ragged and flocculent, and in many places thrown into shallow folds, lying in some situations across, but chiefly along, the axis of the gut.

The microscopic characters of the exudate are pretty uniform. Wilks and Clark²⁹ describe the surface of the tubes, examined with a linear magnifying power of forty diameters, as exhibiting the appearance of a gelatinous membraniform matrix traversed by a coarse network of opaque yellow lines, studded at their points of intersection by similarly colored rounded masses. From the larger network proceeds a smaller secondary network, and in the recesses of this were found, at close and regular intervals, well-defined round or oval openings, with elevated margins, resembling in size and appearance the mouths of the follicles of the great gut. With higher powers the exudate was found in many cases to consist of a structureless basement membrane, which in certain points showed a fibrous appearance, owing doubtless to the presence of filaments of mucin. Numerous irregular granular cells, as well as granules from the breaking up of these cells, thickly studded the surface of the membrane. In the specimens of Wilks and Clark the surface, besides being marked by the opaque yellow lines and dots, presented various foreign matters, such as bile-pigment, earthy and fatty granules, portions of husks of seed, gritty tissues of a pear, a peculiar form of elastic tissue, stellate vegetable hairs, and a mucedinous fungus. Clark, in describing the fibres found between the layers of the exudates, says that they exhibited a very distinct and regular transverse striation, approaching in character that found in the ligamentum nuchæ of the giraffe. Quekett and Brooke have met with the same fibres in the feces. The transverse division depends probably upon beginning decay. The division is sometimes so distinct and complete as to lead, according to Beale,³⁰ to their confounding with confervoid growths. Farre³¹ actually describes the formation as of a confervoid character.

²⁹ Op. cit., p. 232.

³⁰ The Microscope in Medicine, p. 194.

³¹ Trans. Microscopical Society.

Here and there, in my specimens, were observed scattered epithelial cells which were occasionally gathered in patches. Small colored masses of irregular shape, doubtless of fecal origin, were also noticed. The cells imbedded in the matrix, according to the above-quoted observers, consisted of two kinds—one more or less spherical, the other more or less cylindrical. In size the spherical cells varied from ¹/2000 to ¹/800 of an inch in diameter. The smaller cells had no distinct cell-walls. Some of the larger cells were filled with fat-granules, and represented granular cells; others had a single or double vesicular nucleus; a few were acuminated at two opposite points and somewhat compressed. All the other cells possessed demonstrable cell-walls. The cylindrical cells resembled in their general characters those which normally coat the mucous membrane of the larger gut, but they were much more elongated, compressed, and firmly matted together. Many of the more elongated cells were constricted in the middle, and exhibited a nucleus on each side of the constriction. The more or less spherical cells occupied the attached, and the cylindrical cells the free, surface of the membranous tubes.

The perforations in the matrix were of uniform size and appearance, surrounded by elevated margins formed of closely-grouped cylindrical cells, and led to two kinds of pits—one short and flask-shaped, the other long and uniformly cylindrical. The flask-shaped pits were about one-tenth of an inch in diameter and distinctly hollow. The wall of each pit was made up of one or two layers of subspheroidal cells, held together by an amorphous stroma. A few of these follicles contained a deposit which was opaque in situ, and which when broken up was found to consist of large flattened nuclear cells, analogous to those met with in epithelial growths.

The cylindrical pits were also for the most part hollow, about one-sixteenth of a line in length and one-thirty-first of a line in breadth. These walls, devoid of membrane, were composed of small, more or less spherical cells in various stages of development, imbedded in a gelatinous matrix.

In examining the chemical characters of the specimens obtained in my cases the membranes were thoroughly washed, when they were nearly as colorless as the water in which they floated. They were drained on a sieve, and presented a gelatinous appearance, much like the white of an egg. Their specific gravity was about that of distilled water. When treated with strong alcohol, the membranes shrank and assumed a striated appearance. Chemical tests of tincture of guaiacum, peroxide of hydrogen, and others failed to show the presence of fibrin or albumen. Treated with ether, globules of fatty matter were obtained, which were identified by their microscopical characters and by their reaction with osmic acid. By boiling the liquid in which the membranes had been soaked it became faintly hazy, indicating a trace only of albumen. Faint evidence of the presence of this body was also presented by picric acid and Mehu's test. Treated with a weak solution of caustic potassa and heat, the membrane dissolved, leaving a little haziness. The liquid was then filtered, and exactly neutralized with acetic acid, and plumbic acetate added, when a copious precipitate was formed. Mercuric chloride and potassic ferrocyanide failed to produce this effect. From these and other tests used the conclusion was reached that these membranes were composed essentially of mucin.

Both the microscopical and chemical characters of the exudates of the disease under consideration show that they are widely different in nature from those of other diseases. They are evidently a production of the muciparous glands (follicles of Lieberkühn) of the intestinal canal, and consist essentially of mucin. Perroud³² concluded from his analysis that they contain a small quantity of albumen, but are principally formed of the same substance as that which enters into the composition of the epidermis. The exudates of other diseases of the alimentary mucous membrane contain albumen and fibrin, as well as molecular or homogeneous filaments. The ordinary croupous exudate, according to Cornil and Ranvier, always contains filaments of fibrin, sometimes mucin and pus-corpuscles mingled with the cellular constituents, which vary in character with the locality of the inflammation. The filaments form a reticulum in the meshes of which are contained the other elements.

³² Journal de Médecine de Lyon, 1864.

Diphtheritic exudates, as shown by Lehmann,³³ consist of fibrin, a large quantity of fatty matter, and 4 per cent. of earthy phosphates, while its structure is made up of epithelial cells united together, which, becoming infiltrated with an albuminous substance and gradually losing their nuclei and walls, are finally converted into homogeneous branching masses. The cells of these masses are liable to undergo fibrinous degeneration. The inflammation determining the exudate is not confined to the conglomerate glands, but involves all the textural elements of the part affected, and the material of the membrane originates from the capillary disturbance in them.

³³ Lehrbuch der Physiolog. Chemie, Leipzig, 1855.

Andrew Clark³⁴ states that he has observed in his studies of exuded blastema, the product of diseased action in mucous membranes, three varieties. The first is clear, jelly-like, and imperfectly membranous. The second is yellowish, semi-opaque, flaky, and usually membranous. The third is yellowish-white, dense, opaque, distinctly membranous, tough, and rather firmly adherent to the subjacent surface. The first contains only the merest trace of albumen, and no fibrin; the second contains an abundance of albumen, and no fibrin; the third contains both albumen and fibrin in abundance, the latter in a fibrillated form. They all contain the same cell-forms. Yet it is to be noticed that in the first variety there is no evidence of transudation or exudation; in the second, no evidence of a true exudation; and that in the third, in which the existence of a true inflammatory exudation is undeniable, the only additional structural element present is fibre.

³⁴ Op. cit., p. 133.

DIAGNOSIS.—The diagnosis of membranous enteritis can never in its advance, and rarely in its early stages, present much difficulty. Its chronic course, irregular exacerbations, lack of febrile excitement, the persistent derangement of the intestinal canal, the mental depression, the gradual impairment of health, the various visceral complications, and, lastly and chiefly, the peculiar character of the alvine discharges,—stamp the disease with an individuality entirely its own.

The mucous discharges of certain forms of chronic diarrhoea and the membranous discharges of infective dysentery are all so different in physical character, and are associated with such a different complex of general symptoms, that they cannot be confounded with those of the diseases in question. The peculiar irritative quickness of the pulse of ordinary enteritis, according to Powell and Good, suffices to differentiate this disease from membranous enteritis. The peculiarities of the physical and chemical properties of these exudates, already fully dwelt upon, not only distinguish them from those of the above diseases, but also from such dejecta as may contain fragments of undigested connective tissue, of hydatids, or of worms. The flakes of mucus discharged from the bowels in protracted constipation, fissura ani, and in the later stages of cirrhosis of the liver are composed of mucus in which are found imbedded epithelial cells from the colon and mucus-corpuscles. The microscope will also reveal the character of the fatty discharges that may be associated with diseases of the pancreas, liver, and duodenum. The mucous flakes of cholera stools are composed of masses of intestinal epithelium mixed with amorphous and granular matter, crystals of different substances, and, according to Davaine, of parasitic forms, particularly the Circomonas hominis.

Membranous casts from the upper part of the digestive track are, in rare cases, passed by the bowels. One of the most curious instances of this sort is reported by Villermé:³⁵ A woman swallowed a tablespoonful of nitric acid, and seventy days afterward a long membranous exudate, one or two lines thick and of a brown color, was discharged, which corresponded in form with the oesophagus and stomach. The patient died a few days later.

³⁵ Dictionnaire des Sciences médicales, tome xxxii. p. 264.

PROGNOSIS.—The prognosis of the disease as regards life is not unfavorable, but as regards permanent restoration to health and strength the case is entirely different. Theden³⁶ and Hoffman³⁷ have, however, stated that the disease is not an unfrequent cause of sudden death.

³⁶ Remarques et Experiences, tome ii.

³⁷ Med. Ration., vol. v.

Abercrombie³⁸ records a case of death from phthisis complicated with this disease, and Wright another case in which the patient died in an extreme state of marasmus. The acute and subacute forms are more amenable to treatment, and the chances are correspondingly greater of permanent recovery, though in all cases there is a strong tendency to relapse. The chronic forms may almost be enrolled among the opprobria medicorum when once they have made deep inroads upon nutrition and the vital powers, and produced that condition named by Todd the pituitous cachexia (cachexia pituitosa). These cases may, however, be alleviated by judicious treatment, diet, and climatic changes, but repeated relapses may be expected as the rule under slight exciting causes or even without apparent cause. Patients under these circumstances drag out a life of valetudinarianism, but it may be cut short at any time by the supervention of some intercurrent disease, as phthisis, renal degeneration, etc., or, according to Grantham, atrophy of the intestines. Broca³⁹ records two cases of this disease, one of which lasted ten and the other fifteen years. Three of my cases have endured over six years.

³⁸ Inflamm. Affec. of Mucous Memb. of Intestines, pp. 213, 279.

³⁹ Bullétin de la Société Anat. de Paris, 1854.

TREATMENT.—The treatment of membranous enteritis embraces medical and hygienic measures. The medical means have for their object, first, the removal of the membranous exudation when it has once formed; and, second, to correct the conditions upon which its formation depends by improving nutrition and invigorating the nervous system. The severe sufferings of the paroxysms are greatly alleviated and the duration of this stage cut short by freely emptying the bowels. The best means to do this is by the injection of hot water with the long elastic bougie three or four times a day, and to assist this with laxatives. Instead of water, solutions of potassa, soda, and lime-water are preferred by some practitioners. As a rule, the enemata cause considerable discomfort, but in the end are followed by improvement in the condition of the bowels. The best laxative is emulsion of castor oil, but occasionally a mercurial, guarded by the extract of belladonna, will furnish more marked relief. Powell and Copeland say that they have employed with decided advantage a purgative consisting of the compound infusion of gentian and infusion of senna, to which were added ten or twenty minims of liquor potassæ. This was repeated, so that four stools in the twenty-four hours were obtained. Clark preferred to regulate the bowels, when needed, with rhubarb, soda, and ipecac, conjoined or not, as required, with mercury and chalk. Good recommends four grains of Plummer's pill every night, and the bowels kept open by two drachms of sublimed sulphur daily. It should always be borne in mind that all active or irritating purgatives are harmful. The bowels by this treatment will not only be disembarrassed of the membranous exudates, but also of any fecal collection the retention of which would surely cause irritation, as occasionally happens even when there is an apparent diarrhoea. This condition may be easily determined by abdominal palpation. The relief from pain procured by free evacuation of the intestine will be enhanced by the employment of hot fomentations to the abdomen. Despite these means, its severity may, however, demand the administration of narcotics. The best form will be a hypodermic injection of a sixth or a quarter of a grain of morphia; enemata of starch and laudanum are also beneficial. Burrows mentions a case in which he succeeded in allaying nervous irritation by the nightly use of thirty drops of laudanum. The patient noticed that the habitual constipation was increased when the accustomed narcotic was omitted. Bromide of potassium in large doses long continued will also be found useful for the same purpose.

During the intervals of the paroxysms local medication of the bowels and medical and hygienic measures should be had recourse to to prevent the re-formation of the exudates by modifying the vital activities of the intestinal mucous membrane and by restoring the general tone of the constitutional powers. For local treatment the nitrate of silver, sulphate of zinc, the sulphate of copper dissolved in glycerin, the tincture of iodine, and carbolic acid cannot be over-prized. From five to ten grains of the metallic salts, fifteen drops of tincture of iodine, ten of the acid, administered through the long rubber tube, are suitable doses to begin with. I am also in the habit of using stronger solutions by mopping it on to the bowel through the endoscopic tube. Kaempf made frequent and large injections of decoctions of various plants—saponaria, taraxacum, etc.—which he imagined possessed dissolvent and resolvent virtues. Cumming⁴⁰ speaks highly of the efficacy of electricity.

⁴⁰ Lond. Med. Gazette, 3d Series, vol. ix.

For the purpose of improving the general health the preparations of iron are advisable, of which the best are the tincture of the chloride, pernitrate, pyrophosphate, lactate, and potassio-tartrate. Habershon advises infusions of the bitter tonics with hydrocyanic and nitro-muriatic acid. I have found a combination of these acids with henbane and infusion of serpentaria useful. I also employ hot solutions of the latter acid as a local bath over the abdominal region, applied with a large sponge. Clark speaks favorably of the extract of nux vomica and astringent remedies. Simpson praises the oleo-resins under the form of pitch pills and tar, while Clark and others laud copaiba and turpentine. Good advises the copaiba to be given by enema when it cannot be borne by the stomach. Brodie used cubebs in small doses.

The alterative effects of small doses of arsenic, corrosive sublimate, sulphate of copper, etc. may be tried in obstinate cases. Grantham in the early stages of the complaint advises the use of ten grains of iodide of potassium combined with one-quarter of a grain of morphia at bed-time. He also strongly urges the use of cod-liver oil, which, he says, improves the strength and increases the flesh, lessens the spasmodic pains, but does not check the discharges.

Counter-irritation of the abdominal region with tincture of iodine, fly blisters, mustard, etc. has afforded little if any advantage. Dunhill kept a blister open for six months without any good results.

The mineral waters of Pyrmont, Harrogate, and Carlsbad have been found serviceable; the latter, Henoch⁴¹ says, should be preferred before all.

⁴¹ Klinik der Unterleub. Krankheiten, p. 668.

The case will amend more speedily and surely by the adoption of those sanitary measures, as regards clothing, diet, bathing, exercise, and change of climate, which have such important influences upon health. The healthy performance of the functions of the skin is of such paramount necessity in maintaining that of the intestinal canal that the patient should endeavor to avoid any exposure likely to lead to checked perspiration, and should use flannel underwear and stimulate the skin by friction with the hand or the flesh-brush. The diet should be graded to the ability of the stomach to digest and the body to assimilate. Our chief reliance will be upon milk, plain or peptonized, eggs, and beef given in the various forms of acceptable preparations, so as not to impair the tone of the stomach nor clog the appetite by sameness. Such vegetables and fruits as agree with the patient may be allowed. I have tried exclusive diets of milk, farinacea, and meat without marked benefit. All stimulants, tea, and coffee should as a rule be interdicted.

Systematic exercise in the open air and change of climate to a cool, dry, bracing atmosphere will contribute to comfortable existence, if not lead to recovery.

DYSENTERY.

BY JAMES T. WHITTAKER, M.D.

DEFINITION.—Dysentery is the clinical expression of a disease of the large intestine, of specific and non-specific (catarrhal) origin and form; characterized by hyperæmia, infiltration, and necrosis (ulceration) of its mucous membrane; distinguished by discharges of mucus, blood, pus, and tissue-débris; and attended with griping and expulsive pains (tormina and tenesmus).

ETYMOLOGY.—The name is compounded of the two Greek words [Greek: dys enteron], which, though untranslatable literally into English, have long since received the exact Latin equivalent, difficultas intestinorum. With appropriate alteration the same name is still employed in every civilized language in the common as well as the classical description of the disease. The French synonym, colite, locates the anatomical seat of the disease, while the German Ruhr and the English flux express one of its cardinal symptoms, the frequency (flow) of the evacuations.

HISTORY.—Ancient.—In its clinical history dysentery is one of the oldest known diseases, the name being found in common use before the time of Hippocrates, as in the often-quoted passage from Herodotus (443 B.C.), who relates that it and the plague reduced the army of Xerxes on the desert plains of Thessaly.

Fayrer informs us that in the ancient system of Hindoo medicine of the Ayur Veda, and in the commentaries of Dhanwantari, Charaka, and Sussutra, which carry us back nearly three thousand years, and in later Sanskrit writers, dysentery is described by the name of atisar, under two forms—amapake, or acute, and pakistar, or chronic; these again are subdivided into six varieties, ascribed by those ancient sages to changes in air, bile, phlegm, food, or to perturbations of the emotions and passions.

Hippocrates (430 B.C.) makes frequent reference to the disease, the nature of which he regards as a descent of the humors from the brain. "Men of a phlegmatic temperament are liable to have dysenteries," he says, "and women also, from the humidity of their bodies, the phlegm descending downward from the brain."

"The disease is caused," he says more exactly in another place, "by the overflow of phlegm and bile to the veins of the belly, producing ulceration and erosion of the intestine." In his country, at least, it seemed most to prevail in spring, but it was clearly connected with the heat and moisture of this season in Greece—prime factors everywhere in the genesis of the disease: "For when suffocating heat sets in all of a sudden while the earth is moistened by the vernal showers and by the south wind, the heat is necessarily doubled from the earth, which is thus soaked by the rain and heated by a burning sun, while at the same time men's bellies are not in an orderly state, nor is the brain properly dried." Of the prognosis he observes with great acumen, "Dysenteries when they set in with fever ... or with inflammation of the liver and hypochondrium or of the stomach, ... all these are bad. But such dysenteries as are of a beneficial nature and are attended with blood and scrapings of the bowels cease on the seventh or thirtieth day, or within that period. In such cases even a pregnant woman may recover and not suffer abortion;" whereas, "dysentery if it commence with black bile is mortal." Galen comments upon this statement that such a discharge is as incurable as cancer. The practitioner of our day will interpret this assertion, which was repeated with singular unanimity by all the writers of antiquity, with the belief that the black bile was blood, and that such cases really were cancers. Indeed, Paulus Ægineta distinctly says, "Dysentery arising from black bile is necessarily fatal, as indicating an ulcerated cancer."

Thus, although dysentery is among the oldest of the known maladies, and was recognized then as now by the same symptoms, the disease was by no means closely defined or differentiated in ancient times. As Ackermann long ago pointed out, many other affections were included under the term dysentery, and some of the symptoms of true dysentery, notably the tenesmus, were raised to the dignity of distinct diseases.

The gravity of the so-called lotura carnea, the fleshy stools, was fully appreciated by Hippocrates, as is evidenced by the remark that "if in a person ill of dysentery substances resembling flesh be discharged from the bowels, it is a mortal symptom." Fleshy masses, [Greek: xysmata], scrapings of the guts (originally epidermic exfoliations from the bodies of gladiators, used in pills as a tonic), were frequently alluded to by the older writers, more especially by Aretæus, in description of the discharges of dysentery. Hippocrates was also aware of the fact that dysentery may be a secondary as well as a primary malady. "One may expect," he says in speaking of the victims of gangrene, "that such patients will be attacked with dysentery; for dysentery usually supervenes in cases of mortification and of hemorrhage from wounds." Finally, Hippocrates recognized the effects of emesis in relief of the disease with the remark in one of his aphorisms that a spontaneous vomiting cures dysentery.

Celsus (25 B.C.-45 A.D.), the great encyclopædist, whose works "constitute the greatest literary monument since the days of Hippocrates," compiles all the information obtained up to his time; but it is plain as regards dysentery, though he defines it in terms that might stand in a modern text-book, that he has nothing new to add to the knowledge of the Hippocratic school. He named the disease from one of its most prominent symptoms, tormina (tenesmus he considered a separate affection), speaks of the stools as being mixed with mucus and fleshy masses, and in its treatment especially enjoins rest, "as all motion proves injurious to the ulcer."

Aretæus (50 A.D.), of all the authors of antiquity, wrote the most perfect and at the same time the most picturesque account of the morbid anatomy and symptomatology of this disease. The gross appearance of the ulcers in the intestine and the common character of the discharges he describes with the accuracy of the modern pathologist and the ardor of the true clinician. He speaks of the superficial, the deep-seated, the irritable, and the callous ulcer. There is, he says, "another larger species of ulcers, with thick edges, rough, unequal, callous, as we would call a knot of wood; these are difficult to cure, for they do not readily cicatrize, and the cicatrices are easily dissolved." Their tendency to arrest and renewal and their general and local effects he notices at length. "There may be a postponement of their spreading for a long time," he says, "various changes taking place in the ulcers, some subsiding and others swelling up like waves in the sea. Such is the course of the ulcers; but if nature stand out and the physician co-operate, the spreading may indeed be stopped, and a fatal termination is not apprehended, but the intestines remain hard and callous, and the recovery of such cases is protracted." Vivid descriptions he gives of the stools: "Sometimes they are like chopped tallow, sometimes merely mucus, prurient, small, round, pungent, causing frequent dejections and a desire not without a pleasurable sensation, but with very scanty evacuations." Again, they are "fetid like a mortification;" composed of "food now undigested, as if only masticated by voracious teeth, ... the dejection being discharged with much flatulence and noise; it has the appearance of being larger than its actual amount."

Galen (164 A.D.) attempted to correct the pathology of his contemporaries, who considered all bloody discharges dysenteric. There are four distinct varieties of bloody stools, he claims, only one of which, that due to ulceration of the intestine, deserves to be called dysentery. The bilious stool he derived from melancholy, and the fleshy stool from disease of the liver. But, though Galen regarded the presence of blood as a necessity, he was well aware of the fact that the stools contained ingredients other than blood. It was Galen who first used the word scybala ([Greek: schybala], feces) to express the small, solid masses of excrementitious matter often voided with the stools. In his treatment of the disease he made much use of the various drying earths, the Samian, Lemnian, Armenian, the sources of which he made long journeys to visit in order to become better acquainted with their properties, and which are better substituted in our day by bismuth, chalk, magnesia, and the carbonate of iron. It is the distinguished merit of Galen to have called special attention to the anatomical seat of the disease. Ulceration of the intestine he claimed as the very essence of the disease, and all the physicians of his day, he maintained, regarded as dysenteric only such cases as are attended with ulceration.

Galen was the exponent of the flower of Grecian, we might say of ancient, medicine. With very few exceptions, the later writers, if they do not obscure the original text with their speculations, are content to simply paraphrase the observations of their predecessors, and the subsequent contributions to the ancient history of dysentery may be briefly summed up in a few additional notes.

Coelius Aurelianus (400 A.D.) adopted the humoralistic doctrine of Hippocrates and regarded dysentery as an intestinal rheumatism (catarrh) with ulceration. He seems to have been the first author to recognize the cardinal fact that dysentery, notwithstanding the number of its stools, should be classed with the diseases which constipate the bowels, or, as it was centuries later aptly put by Stoll, "ut hanc morbis adnumeres alvum potius occludentibus," and he blames Erasistratus for using nothing but astringents, whereas many cases of dysentery require laxatives. It is worthy of note that Coelius Aurelianus ascribes the first use of opium in the treatment of dysentery to Diocles of Carystus (300 B.C.), who administered the juice of poppies combined with galls. By the time of Galen opium was so freely used in the treatment of the fluxes as to call for protest against its abuse.

Alexander of Tralles (575 A.D.) is often credited as having been the first to locate the disease in the large intestine. The truth is, he suggested various rules by which the seat of the disease, whether in the small or large intestine, might be definitely determined. But none of these rules—the seat of the pain, for instance, whether above or below the umbilicus, and the interval of time between the pain and discharges, whether long or short—possess the least diagnostic value or add to the attempts in this direction of previous writers—Aretæus, Archigenes, and Galen. Like these, his predecessors, he recognized an hepatic dysentery with discharges of bloody serum, which he attributed with them to atony of the liver, but more boldly than they, and with characteristic independence, he ventured to treat his patients with fresh vegetables and fruits, damsons and grapes.

Paul of Ægina (660 A.D.) locates the disease in the rectum, and gives a graphic account of its symptomatology. He made the mistake of many later practitioners in regarding as a separate disease a symptom, tenesmus, which he describes as an irresistible desire of evacuation, "discharging nothing but some bloody humor, which is the cause of the whole complaint, being an oedematous inflammation of the rectum which creates the impression of feces lodged in the intestine and a desire of evacuation." "Dysentery," he continues, "is an ulceration of the intestines, sometimes arising from the translation of tenesmus, and sometimes being of itself the primary affection; and is attended with evacuations at first bilious and of various colors, then accordingly bloody, and at last ichorous, like that which runs from dead bodies."

In curious contrast to these accurate observations is the absurd suggestion of an obsolete therapy (Galen), that the dried dung of dogs who had eaten bones, when drank in milk which has been curdled by having heated pebbles put into it, is of great service; but as an offset to this freak of fantasy is the renewed advocacy of warm milk, fallen somewhat into disuse since the days of Hippocrates and Galen: "And milk itself moderately boiled is an excellent thing"—a recommendation of the milk diet which now plays such an important rôle in the treatment of so many diseases of the alimentary canal.

Modern.—From this brief survey it is seen that the writers of antiquity left nothing in the symptomatology of dysentery for subsequent authors to describe. All further advance in our knowledge of this, as of all diseases, was now rendered impossible by the extinction of the light of science in the long night of the Middle Ages, whose gloom deepens with succeeding centuries and whose shadows fall close up to our own times.

The modern history of dysentery may be said to begin with Daniel Sennertus, whose first Tractatus de Dysenteria was published at Wittenberg in 1626. Sennert gave the deathblow to tenesmus as a distinct disease, or as even a pathognomonic sign of dysentery, showing that it is often present in purely local troubles, ulcers, fissures, hemorrhoids, etc., or is due to disease of other organs—stone in the bladder, tumors in the womb, etc. He recognized sporadic and epidemic attacks of the disease, and described under the terms fiens and facta forms which coarsely correspond to the catarrhal and diphtheritic varieties of modern pathologists. Improper food, unripe fruits, at least, cannot be the cause of dysentery, because, he shrewdly observes, the epidemic of 1624 began in May, before the fruits were ripe, and ceased in autumn, when they were ripe and in daily use. Moreover, sucklings at the breast suffered with the disease. Nor could moisture alone account for the disease, as this epidemic occurred after an unusually hot and dry spring and early summer. Some other cause must be invoked, and this other cause is perhaps the occult influence of the constellations and planets—an explanation which he afterward admits to be only an asylum of ignorance. In the treatment of the disease the indication should be to heal the abraded or ulcerated intestine; but since this cannot be done unless the cause is first removed, "the abrading, eroding humor should be evacuated and absterged, at the same time its acrimony mitigated and corrected; then the flux should be checked by astringents, and the pain, if vehement, lenified and removed." Purgatives should be repeated until all vicious humors are discharged.

Sydenham colored his descriptions of the epidemic which he witnessed in London in 1669-72 with the artistic touches of the master's hand. "The disease sets in," he says, "with chills and shivers. After these come the heat of the fever, then gripings of the belly, and lastly stools. Occasionally there is no fever; in which case the gripes lead the way, and the purging follows soon after. Great torment of the belly and sinking of the intestines whenever motions are passed are constant; and these motions are frequent as well as distressing, the bowels coming down as they take place. They are always more slimy than stercoraceous, feces being rarely present, and when present causing but little pain. With these slimy motions appear streaks of blood, though not always. Sometimes, indeed, there is no passage of any blood whatever from first to last. Notwithstanding, provided that the motions be frequent, slimy, and attended with griping, the disease is a true bloody flux or dysentery." The efficacy of opium in its treatment causes him to break out in praises of the great God who has vouchsafed us a remedy of so much power. But Sydenham was too good a practitioner not to know that all treatment must be prefaced with laxatives. For "after I had diligently and maturely weighed in my mind," he says, "the various symptoms which occur during this disease, I discovered that it was a fever—a fever, indeed, of a kind of its own—turned inwardly upon the bowels. By means of this fever the hot and acrid humors contained in the mass of the blood, and irritating it accordingly, are deposited in the aforesaid parts through the meseraic arteries." The indications then were plain—viz. "after revulsion by venesection to draw off the acrid humors by purging." It was the frequent and successful practice of Sydenham also to drench the patient with liquids, per os et per rectum—a mode of treatment which both he and the learned Butler, who accompanied the English ambassador to Morocco, where dysentery was always epidemic, hit upon, "neither of us borrowing our practice of the other." Butler declared that the method of deluging the dysentery by liquids was the best. But many attacks are cured almost on the expectant plan alone. This was the case with the excellent and learned Daniel Coxe, Doctor of Physic, in whom "the gripes and bloody motions ceased after the fourth clyster. He was kept to his bed, limited to milk diet; and this was all that was necessary in order to restore him to perfect health."

Zimmermann (1767) did not believe that improper food could be a cause of dysentery, as in the epidemic of 1765 fresh grapes were plentifully supplied to patients and proved an excellent remedy. He also noticed the muscular pains (rheumatism) which had been mentioned by Sydenham before him, and the paralyses first noticed by Fabricius in 1720, as occurring in the course of, or as sequelæ to, the disease. It was only contagious, he thought, in bad cases, when the stools have a cadaveric odor. But his main and most useful contributions were in the field of therapy. He discarded venesection entirely, was among the first to recognize the value of ipecacuanha, and objected strenuously to opium until the cause of the evil was expelled. Hence he was vehemently opposed to all astringents, to the use of which he ascribes the rheumatisms and dropsies which sometimes occur. Wines and spices were likewise put under ban; whey he permitted, but not milk, and water freely, but always warm. Barley-water and cream of tartar were sufficient food and medicine for ordinary cases, while camphor and cinchona best sustain the strength in bad cases.

Pringle (1772) observed the frequent occurrence of dysentery coincidently with malarial fever, and was a firm believer in the contagion of the disease. He claimed that the foul straw upon which the soldiers slept became infectious, but maintained that the chief source of infection were the privies "after they had received the dysenteric excrements of those who first sicken." It is spread in tents and in hospitals, and may be carried by bedding and clothing, as in the plague, small-pox, and measles. Neither food nor drink propagates the disease, he thinks, for, so far as the fruits are concerned, he too had seen it prevail before the fruits were ripe. The first cause of the disease is "a stoppage of the pores, checking the perspiration and turning inward of the humors upon the bowels." Antimony was his specific in its treatment. He was also fond of Dover's powder in its relief, and preferred fomentations to opium, which "only palliates and augments the cause." The best drink for patients with dysentery was lime-water (one-third) and milk.

This period of time is made memorable in the history of dysentery, as of nearly all internal diseases, by the contributions from direct observation upon the dead body by the father of pathological anatomy, John Baptist Morgagni (1779). From the days of Hippocrates down, the seat of the disease had been, as has been shown, pretty accurately determined, and the same acumen which enabled the clinicians to localize the affection had inspired them, as we have seen, to define and describe its nature. But any descriptions from actual post-mortem examinations were not put upon record until the beginning of the sixteenth century, when were published the posthumous contributions of Benivieni (1506-07). In his description of the lesions of the disease he says that "the viscera displayed internal erosion from which sanies was continually discharged." Nearly three centuries elapsed before Morgagni made his anatomical studies—an interval of time void of any contributions from pathological anatomy; and so little attention was paid to this branch of medical science that the descriptions of Morgagni and of his more immediate successors failed to excite any general interest or make any permanent impression. Morgagni himself, while he fully recognized their significance, did not consider the ulcerations of dysentery as absolutely essential to the disease, as many cases, even fatal ones, did not exhibit them at all. They were not liable to be mistaken for the lesions of typhoid fever, the ulceration of Peyer's glands, because, though they may, they only rarely, coexist in the same subject. As to the membranous fragments sometimes evacuated with the discharges of dysentery, Morgagni showed that they are occasionally true fragments or shreds of the intestinal coats, as has been maintained by the older writers, Tulpius and Laucisius, but are far more frequently nothing else than inspissated mucus—conceptions which subsequent studies with the microscope have fully confirmed.

In view of the general disregard of direct observations, it is therefore not surprising to learn that the nature of the intestinal lesions gradually fell into oblivion or at least became underrated in its import. But it is a matter of surprise that Stoll (1780) was able to declare as the result of autopsies made by himself that, although the colon is thickened and inflamed, ulcerations in dysenteries are very rare. This distinguished author did not at all believe in the contagion of the disease, as he had never seen it attack physicians or nurses. It developed, he thought with the older writers, as the result of exposure to cold during a perspiration. He emphatically insisted upon the frequency of rheumatism as complicating the disease, and describes in proof a number of cases of painful swollen joints during and subsequent to the attack. It was his especial merit to have succeeded in dispensing with the acrid bile as a cause of the disease, maintaining that hepatic derangements were only accidental complications, and thus disposed, but only for a time, of bilious dysentery in so far as it was supposed to depend upon defective or abnormal action of the liver.

But Annesley (1828) soon reinstated the liver in the pathology of dysentery, with the exhibition of colored plates displaying abscess of the liver in connection with the disease, as well as illustrating the displacements and constrictions of the colon which sometimes occur in its course.

The fourth decade of our century now brought in the anatomical contributions of Cruveilhier and Rokitansky, to be followed later by those of Virchow, upon which the modern morbid anatomy of the disease is based; while the labors of the Indian physicians and of Copeland, Parkes, and Vaidy put us in possession of the facts pertaining to its general pathology. Fayrer has quite recently published the results of his vast experience with dysentery in India, an important contribution to the practical study of the disease, and Hirsch has treated exhaustively of its medical geography. But the merit of publication of the most complete chapter or work upon dysentery that has ever been written anywhere belongs to, and is the especial pride of, our own country. It constitutes the bulk of the second volume of the Medical and Surgical History of the War of the Rebellion. It is a veritable encyclopædia of knowledge, not only upon the subject of which it treats, but upon all subjects immediately or even remotely collateral to it, and is a lasting monument to the labor and the learning of its author, Joseph J. Woodward, Surgeon of the United States Army.

GENERAL REMARKS.—Dysentery may be a primary or a secondary disease. As a primary disease it occurs in sporadic, endemic (often closely, sometimes curiously, circumscribed), or epidemic form, and is either acute or chronic, according to the nature of its symptoms and lesions. The ancient types of sthenic and asthenic or adynamic, typhoid, bilious, and malarial dysenteries belong rather to history than to modern medicine. The classification of cases in general use at present—viz. the catarrhal and croupous or diphtheritic forms—has reference rather exclusively to the nature of the lesion, and is hence extremely defective. Nor are the divisions (as in cholera) into sporadic and epidemic forms much more satisfactory, in that they indicate simply the range or extent of the disease, and by no means define a separate array of symptoms or lesions; precisely the same symptoms or lesions being encountered in individual cases of either form. None of these divisions clearly indicate differences in etiology, upon which factor alone can any acceptable division of cases be based. Perhaps less objection may be urged against the assumption of catarrhal and specific forms, including under the provisional term catarrhal all the cases which cannot as yet be accounted for by the action of a special or specific cause.

It will become apparent in the study of the etiology of dysentery that while any of the factors invoked may suffice to produce the catarrhal (sporadic) form, none will explain the specific (epidemic) form of the disease; both forms may be alike in their lesion and signs, but they differ widely in their cause. In other words, dysentery is only a clinical, and is in no way an etiological, expression of a disease. In this respect dysentery finds its analogue in a much grosser lesion of the bowels—namely, occlusion, acute or chronic, which, while it presents pretty much the same train of symptoms, may depend upon a great variety of causes, as impaction, strangulation, intussusception, etc. While any of the causes cited may be sufficient to excite the catarrhal form of the disease, the same causes may stand to the specific form only in the relation of predisposing agents. Or, as Maclean has better put it, "It appears that many of the so-called causes of dysentery must be regarded more as acute agents of propagation than of causation."

As a secondary disease dysentery occurs in the course of, or as a sequel to (not infrequently as the terminal affection of), pyæmia and septicæmia (puerperal fever), typhus and typhoid fevers, pneumonia, Bright's disease, variola, scarlatina, abscess of the liver (though the order of sequence is here oftener reversed), scorbutus, marasmus from any cause, tuberculosis, and cancer. It must not be forgotten, however, of these latter affections that each produces its own lesions in the large intestine, which are not to be confounded with those of genuine dysentery.

The view that dysentery shows a periodicity of recurrence at certain distinct intervals or cycles—three, five, or ten years—is entirely without foundation in fact; but there is strong ground for believing that the disease is gradually abating both in frequency and virulence with improvements in sanitation and hygiene. Thus, Heberden shows that the number of deaths set down in the seventeenth century under the titles of bloody flux and gripings of the guts was never less than 1000 annually, and in some years exceeded 4000, whereas during the last century the number gradually dwindled down to 20 (Watson)—a number which is certainly a misprint for 200; and Aitken states that as a cause of death it has been decreasing since 1852. Geissler also remarks¹ that the variation in epidemics is nowhere so well illustrated as in the case of dysentery. A noticeable reduction in the number of cases in England began about 1850, and has continued almost without interruption to the present time, so that now (1880) six to eight times less cases occur than in the forties. The same diminution has been noticed in Bavaria and Sweden. In Sweden the cases treated by physicians in 1857 numbered no less than 37,000, with over 10,000 deaths; whereas now the number is reduced to 400-500 a year, and the mortality has experienced a corresponding reduction from 20-30 to 6-8 per cent.

¹ Periodische Schwanderungen der wichtigsten Krankheiten.

At the same time, it is known of dysentery that it sometimes shows an almost freakish recurrence after long intervals of time, appearing in a place for many decades free from the disease, to establish itself there for years as a regular endemic malady, not to disappear again for a long series of years; in which respect, Hirsch remarks, it much resembles malaria.

Allusion has been already made to the occasional curious circumscription of the disease in definite localities. In fact, dysentery, even when late to assume the proportions of a widespread epidemic, begins, as a rule, and is confined for a time, in individual enclosed regions—prisons, barracks, hospitals, etc.; and in the process of dissemination it is rather characteristic of the disease to leap over or to spare intervening territory and appear in new foci at some distance from its original seat. A direct irradiation or linear transmission of the disease is the exception, and not the rule. The significance of this fact will become evident in the study of the etiology of the disease.

Dysentery is pre-eminently a disease of army life, its victims among soldiers numbering more than all other diseases together. Sir James MacGrigor, Medical Superintendent of the British army, called it the scourge of armies and the most fatal of all their diseases. Aitken says that "it has followed the tracks of all the great armies which have traversed Europe during the continental wars of the past two hundred years." It decimated the French, Prussian, and Austrian armies in 1792. In Cape Colony in 1804 every fourth man among the soldiers was attacked with the disease, and of those attacked every fifth man died. In Napoleon's campaign in Egypt dysentery numbered one-half more victims than the plague; Kinglake says that 5000 men died of dysentery alone in the war of the Crimea; and in our own country during our Civil War from 1861-65 chronic camp dysentery was the cause of more than one-fourth of all the diseases reported, the mortality being at the rate of 12.36 per 1000.

Woodward relates that the dysenteries, acute and chronic, with diarrhoeas, made their appearance in the new regiments at the beginning of the war, and, though mild at first, quickly assumed a formidable character. "Soon no army could move without leaving behind it a host of the victims. They crowded the ambulance-trains, the railroad-cars, the steamboats. In the general hospitals they were often more numerous than the sick from all other diseases, and rivalled the wounded in multitude. They abounded in the convalescent camps, and formed a large proportion of those discharged for disability." Most of the prisoners died of this disease, and great numbers succumbed to it on retirement to their homes after the cessation of the war. It is the story of many a campaign, Eichhorst says, that dysentery kills more men than the enemy's guns.

The fact that it sometimes shows itself in periodic form or with periodic exacerbation, that it is sometimes successfully treated with quinia, and that, as has been noticed from the days of Hippocrates down, it prevails in greatest intensity in malarial regions, has given rise to the view that dysentery is a malarial disease. This view, which was strongly advocated by many of the older writers, Senac, Fournier, Annesley, met with renewed support at the hands of many of the surgeons in our Civil War. But wider observation has shown the fallacy of such a view; for not only may the diseases prevail entirely independently of each other in malarial regions, but there are regions where one does and the other does not exist. Thus Huebner quotes from Rollo concerning St. Lucie (West Indies), a town situated on a mountain in the midst of a swampy country in which both dysentery and malaria abound, while the town itself is almost free from dysentery; and Dutrolan cites Réunion as a place where marsh fevers do not occur, while dysentery is very common. Bérenger-Féraud² scouts the idea of any such connection. "Let us mention only St. Pierre de la Martinique," he says, "where there is not a piece of marsh as big as a hand, but where dysentery has made great ravage more than once. We might cite also Mauritius, Gibraltar, Malta, New Caledonia—places exempt, or almost exempt, from malaria, but often visited by dysentery."

² Traité théorique et clinique de la Dysenterie, etc., Paris, 1883.

The view that dysentery is a form of typhus or typhoid fever (Eisenmann) or scurvy needs no refutation in the light of existing knowledge regarding the pathogenesis and pathology of these affections. These diseases may often complicate, but can never cause, dysentery.

Dysentery is a disease which spares no age, sex, or social condition, the seeming greater suffering of the poorer classes being due to the filth, food, darkness, dampness—in short, to the bad sanitation—of poverty.

Though the disease is often confined exclusively to soldiers in the midst of a civil population, examples are not wanting of an exclusive selection of civilians or of an indiscriminate attack in every direction. Lastly, dysentery is a disease which may recur repeatedly in the same individual, one attack rather predisposing to than preventing another.

ETIOLOGY.—Dysentery is an omnipresent disease. "Wherever man is," Ayres observed of it nearly a quarter of a century ago, "there will some of its forms appear." But the character of the form, and more especially the extent and severity of the disease, vary in extreme degree with the conditions surrounding the abode of man. No one of these conditions affects the disease so markedly as the climate. It is the testimony of Hirsch, based upon the study of seven hundred epidemics of the disease, that no other disease is so dependent upon the influence of the climate. The home of dysentery is the tropical zone. It prevails in greatest frequency and virulence in the tropics, and in those regions of the tropics where the characteristics of this zone are more pronounced, diminishes in intensity in the temperate regions, and occurs only in sporadic form farther north. At 40° latitude the line may be pretty sharply drawn; beyond it dysentery as an epidemic is almost unknown.³

³ Shakespeare (Troilus and Cressida) cites "griping of the guts" among the "rotten diseases of the south."

India has been from time immemorial the hotbed of this disease. Henderson says it is perhaps more fatal to natives than all other diseases put together, and Hutchinson, Hunter, and Tytler observe that it causes three-fourths of the deaths among the natives of Hindostan. In Egypt the disease is indigenous, and is, according to Frank, post pestem maxime timendus. Greisinger reports that one-half of all the autopsies made by him in Egypt showed dysentery as a primary or secondary affection. It is epidemic here at all times, Roser says, and all fatal cases of acute or chronic disease finally perish with it.

Similar testimony might be adduced from a large part of Africa, much of Asia, the Indian Archipelago, and the West Indies. It rages "murderously" in Peru, causing a mortality in some epidemics of 60 to 80 per cent., and occurs in this country not only in the valleys, but in cities and provinces at the lofty elevation of 8000 to 13,000 feet.

Heat, moisture, vegetable decomposition, and sudden atmospheric change are the distinguishing characteristics of southern climes, and the study of the etiology of a disease incident or indigenous to these conditions calls for an investigation of these various factors.

It is well established of dysentery that it occurs for the most part in the hottest season of the year. Of 546 epidemics tabulated by Hirsch, 404 prevailed in summer and fall, 113 in fall and winter, 16 in spring and summer, and only 13 in winter. Fourteen-fifteenths of the whole number of epidemics occurred in the months of June to September. And it is corroborative of these conclusions that of 1500 deaths from dysentery in the cities of Boston, New York, Philadelphia, and Baltimore from 1816 to 1827, 1100 occurred in the months of July, August, and September. In fact, the Census Reports (1860-70) of our country show the maximum mortality in August and September, and the minimum in January and February.

The prevalence of unusual heat may also call out an epidemic in places where the disease usually shows itself only in endemic or sporadic form. Thus, the severe epidemic of 1540 in England was preceded by a heat so intense as to dry up the wells and small streams, in consequence of which many cattle died of thirst; and the epidemics of 1583 in Germany, of 1758 in France, and of 1847 in our own country, were characterized in the same way. Interesting in this connection is the statement of Frick concerning the epidemic in Baltimore in 1849, who found the cases to increase and decrease almost in proportion to the elevation and depression of temperature. The epidemic of Weimar in 1868, where 12,000 people fell ill with the disease, illustrated the rule when it ceased suddenly on the approach of cool weather at the end of August.

But that heat alone is not sufficient to account for the genesis of the disease is apparent from the occasional occurrence of it in the tropics in the colder seasons of the year; in the colder climates, Russia, Sweden, and Canada; and in temperate regions during exceptionally cool seasons, as in Plymouth in 1769, London in 1808, Massachusetts in 1817. Moreover, the temperate zone is often characterized by seasons of unusual heat, during the prevalence of which dysentery may be almost unknown. Thus, during the summer of 1881, in Cincinnati, the thermometer scarcely fell below 95° F. for weeks at a time, and was often nearly 100° during the entire night, but the records at the Health Office show that while cases of heatstroke were alarmingly frequent, dysentery was unusually rare during the entire season.

That moisture cannot act more, at most, than as an occasional predisposing cause of dysentery is sufficiently clear from the statement of Hirsch, that of 119 epidemics, 62 commenced or were preceded by wet and 57 by dry weather. In truth, dryness long continued and excessive heat have already been invoked as remote causes of the disease. But moisture, as contributing to, or being a necessary element of, vegetable decomposition, the third characteristic of tropical regions, is entitled to further consideration. Annesley observed that among troops stationed in the vicinity of rivers, canals, and places abounding with emanations from the decay of animal and vegetable matters dysentery became extremely prevalent and assumed a more or less malignant nature; and Baly, who studied the disease in its famous outbreak in the Milbank Penitentiary, remarks that "it is greatest at those seasons and in those states of the atmosphere which most favor decomposition of organic matter in the soil."

In Africa it has been noticed that dysentery appears with the rainy season, to disappear only at its close; and the same observation has been made of Bengal, while in Lower Egypt the disease follows the inundations of the Nile. Burkhardt says of 10,000 cases that one-half occur in wet hot seasons, two-fifths in dry hot seasons, and but one-tenth in cold seasons. Moreover, the removal of camping-grounds to dry localities has often arrested the disease or checked its further dissemination. Thus, Mursinna states that the removal of the army of Prince Henry of Hesse from Nîmes, where the disease raged fearfully, to Leitmeritz was attended by its immediate cessation, notwithstanding the fact that the soldiers ate large quantities of fruit. A statement of Dillenius, quoted by Heubner, is in this connection exceedingly instructive: "Dillenius had to march with a dysentery hospital of more than 500 patients from July 26 to August 3, 1812, and it required four whole days to accomplish an ordinary nine or ten hours' march. The patients, extremely exhausted, were finally put into a sheep-shed. Here, in the fresh air and lying on hay, they all improved very quickly. By advice of the physician they ate for medicine the fresh whortleberries which they themselves had picked." Werneck attributes the exemption of the city of Halle since the end of the last century to the draining and drying of the neighboring marshes.

On the other hand, numerous observations go to prove that dysentery is likewise prevalent in dry sandy soils where the factors so necessary to the production of malaria are entirely unknown. Thus, Hirsch quotes from Harthill to the effect that dysentery never occurred among the English troops in Afghanistan until they entered upon its thoroughly dry and sandy plains; and from Lidell, who declared that the disease prevailed most in Panama in March, the dry season at this place. Again, a striking confirmation of exemption from dysentery in a marshy region is offered in the Antilles at Grande-Terre, "a wet, marshy plain severely visited by malaria, but used by patients attacked with chronic dysentery at Basse-Terre as the safest place of refuge and recovery."

The rôle of moisture and vegetable decomposition may be, then, summed up in the words of Annesley, that "all situations which furnish exhalations from the decay of animal or vegetable productions under the operation of a moist and hot state of the atmosphere will always occasion dysentery in the predisposed subject—circumstances which, with other causes [italics ours], combine to generate the disease."

Atmospheric vicissitudes, checking of perspiration, catching cold, are synonyms in the present popular as in the ancient professional conception of the genesis of dysentery. "Of the remote causes of dysentery," Johnson says, "I need say little; they are the same in all parts of the world—atmospheric vicissitudes." And in making this statement the author expresses the almost universal testimony of the Indian physicians. "Sudden change of temperature," observes Kaputschinsky of the Trans-Caucasus, where dysentery is rife, "is in this region no rarity. The sultry heat of noon often alternates with a cutting cold wind, and vice versâ. In the same place is now a warm, now a cold, now a glowing hot breeze, and such changes most predispose to dysentery." And McMullin says of the Barbadoes that "it is a curious fact that this disease is most prevalent where from the immediate contiguity of mountains sudden vicissitudes of temperature are experienced." Didelot says also of South France, "It is not the fruits, as people still believe to-day, which act as causes of dysentery, but the sudden variations of the air." Ruthay remarks of the dysentery of China that the most common cause is a chill caught by sleeping in a draught uncovered or in the open air. Metzler attributes the exemption of Stuttgart (since 1811) from any great epidemic to the fact that the city lies in a valley open only to the east, which permits no contrast of hot days and cold nights; and Seeger, in speaking of the epidemic which occurred in Ludwigsberg in 1872 (a city of twelve thousand population, where no epidemic of any kind had appeared since 1834, and where 870 were suddenly attacked with dysentery) that it first broke out in Kaffeeburg in two streets exposed to the wind, and thence spread to different parts of the city. Exposure of the body, especially the abdomen, during sleep or when perspiring, the sudden laying aside of flannel body-clothes, are proceedings, Fayrer says, pregnant with danger in dysenteric regions. A lamentable dysentery appeared, according to Trotter, on board H.M.S. Berwick Oct., 1780, "in consequence of the hurricane on the fifth of the month, by which the clothes and bedding of the seamen, and indeed all parts of the ship, were soaked in water, and many of the men slept for nights together on the wet decks overcome with fatigue and debilitated from want of food." Fayrer also quotes from Moseley the observation that "it often happens that hundreds of men in a camp have been seized with the dysentery almost at the same time after one shower of rain or from lying one night in the wet and cold."

As illustrating the conjoined operation of all these various causes, together with filth and foul effluvia, more especially exposure to cold, the story of dysentery was never better told than by Sir James MacGrigor, who, in speaking of the Peninsular campaign, remarks that "the army during June as well as July was traversing Castile, where it was exposed to the direct influence of a burning sun darting its rays through a sky without a single cloud, the troops marching and fighting during the day, and bivouacking during the night on arid, unsheltered plains. They felt at times every vicissitude of heat and cold. In the rapid advance they could not be regularly supplied with food or had not time to cook it, and not unfrequently indulged in bad wine and unripe fruit." ... The thousands of sick (chiefly from diarrhoea, dysentery, and remittent fever) were hurried off to Ciudad Rodrigo, the nearest hospital-station to the frontier of Portugal, a town "composed chiefly of ruins with very narrow streets," ... and from having been "so much the object of contest, and alternately the site of the hospitals of all the contending armies, nearly twenty thousand bodies were calculated to have been put into the earth either in the town or under its walls in the course of a few months." ... "It may easily be conceived," the author adds, "in what state cases of dysentery must have arrived after having sustained a journey in extent from four to twenty days, conveyed chiefly in bullock-carts or on the backs of mules, sometimes under incessant rain for several days together."

It is really quite superfluous to cite further opinions or examples in illustration of a fact which is so universally conceded as to be exaggerated in its general significance. Taking cold is the common idea of the cause of dysentery, and is always a satisfactory explanation in a case of obscure origin in this or any disease, even though the patient may be able to recall no possible exposure. The physician himself contents himself only too easily with resort to this refuge, and with further appeal to the locus minoris resistentiæ, as the explanation of the seat of the disease, which he hopes to cure with the aid of the vis medicatrix naturæ. But taking cold is only a popular paraphrase for contracting a disease, and will bear no scientific analysis of its meaning. Mere reduction of temperature will certainly not produce a disease whose habitat is the hottest zone, nor will a sudden chill of the surface be accepted as a sufficient cause so long as men daily remain exempt after a sudden plunge into cold water. Some other factor must be invoked to account for the outbreak of specific (epidemic) dysentery.

The influence of the nervous system, the mechanical and chemical or specific action of the ingesta and dejecta, remain to be especially considered in the etiology of the disease.

The influence of the nervous system is more directly seen in the production of diarrhoeas than dysenteries, but that sustained disturbances of the emotions play an important part in the production of dysentery is shown by the greater frequency of the disease among prisoners of war. In the Franco-Prussian war the French prisoners suffered more than the Germans, and the records of prison-life in our own war, at Andersonville, Libby, and Salisbury, furnish ghastly chapters in the history of this disease. Many other factors contribute to the development of the disease under such circumstances—in fact, all the cruelties of man's inhumanity to man—but the influence of the nervous system is too plain to be mistaken. The communication between the cervical ganglia and the sympathetic nerve-fibres which preside over the cerebral circulation and regulate intestinal peristalsis has been invoked (Glax) in explanation of the direct action of the brain upon the intestinal canal. Curious in this connection is the claim of Savignac, who considered dysentery a disease of the nervous system because in two cases he found spots of softening in the spinal cord.

The noxious action of irritating articles of diet has been recognized in the production of dysentery from the earliest times. Aretæus mentions acrid foods, and Aëtius crudities, as directly causing the disease; and unripe fruits have been especially stigmatized from the days of Galen down. Decomposing, fermenting food and drink cause diarrhoea much more frequently than dysentery, but if the irritation be severe or prolonged, or be superimposed upon a catarrhal state, a diarrhoea, it is claimed, may pass over into dysentery. Impurities in drinking-water were charged with causing dysentery by Hippocrates himself, with whom Avicenna fully coincided; and the view that epidemics of the disease are caused in this way has been abundantly advocated ever since. So far as running water is concerned, the researches of Pettenkofer have shown that all impurities are speedily destroyed, for even at the distance of a few rods from the reception of sewage the water is perfectly safe. Nor does standing water lack the means of purification, provided it be sufficiently exposed to the air. The observations of Roth and Lex have shown that the water of the wells of fifteen churchyards in Berlin contained nitrates in less quantity than the average wells in the city; and Fleck made a similar statement with regard to the wells of Dresden. But no one in our day would rely upon a mere chemical analysis in the detection of the organic poisons or particles of disease. It is the physiological test which remains the most conclusive, and the evidence in favor of the production of dysentery by the ingestion of drinking-water poisoned by the reception of excrementitious matter, especially the dejecta of disease, is as positive as in the case of typhoid fever. Thus, De Renzy found that the number of cases of dysentery "immediately decreased at Sibsagor (India) so soon as better drinking-water was obtained from wells deeply sunk and lined with earthenware glazed pipes;" and Payne found that the cases of dysentery (as well as diarrhoea and lumbrici) almost disappeared from the asylum at Calcutta as soon as the habit of drinking water from the latrines was stopped. In face of such facts, which might be infinitely multiplied, one would hesitate to subscribe to the statement of Fergusson that "true dysentery is the offspring of heat and moisture, of moist cold in any shape after excessive heat; but nothing that a man could put into him would ever give him a true dysentery."

The relation of the action of the dejecta must be studied from the double standpoint of the development and the dissemination of the disease, as originating the catarrhal form by mechanical or chemical irritation of the intestinal mucosa, and as spreading the specific form by direct or indirect infection.

By the time the contents of the alimentary canal have reached the colon they have become, through absorption of their fluids, more or less inspissated, and hence as hard, globular masses fill the sacculi of the large intestine. Mechanical irritations by crude, indigestible residue of any kind of food, more especially of vegetable food, or chemical irritations, as by fermenting food, accumulate in this region, fret the mucous membrane into a state of inflammation, even ulceration, and produce the anatomical picture and the clinical signs of dysentery. If there be a superadded or pre-existent catarrhal condition of the mucosa or a defective peristalsis of the muscular coat, which is sluggish enough at best, the development of a pathological state is much facilitated. And there is no doubt that the dysentery of the tropics is increased by the bulky, indigestible, feces-producing character of the food.

The anatomical construction of the colon may also favor these processes by its mere abnormal length or size or by duplicatures in its course. The protracted constipation of the insane, in whom the transverse colon is often found elongated or displaced—to assume the well-known M-form, for instance—may partially account for the frequency of dysentery in these cases (Virchow), though the neglect which comes of preoccupation of the mind, with the general inhibition of peristalsis, is a more frequent cause of the constipation.

Wernich (1879) sums up the action of the feces, independently of a specific cause, in attributing the dysentery of the tropics, aside from the great changes of temperature, to (1) bad aborts, the dejecta being deposited in all parts of the towns or into an opening made in the floor of the hut, with which is associated total lack of personal cleanliness; (2) to the diet, which causes a large amount of feces; and (3) to the relaxation of the intestine in general, permitting accumulations of infecting matter.

Upon the question of the propagation of the disease by the dejecta rest in great measure the all-important problems of a specific virus and of the contagiousness of the disease.

It is the almost universal opinion of those who have had the opportunity of widest observation that epidemic dysentery arises from, or is due to, a specific cause, a miasm, a malaria (in its wide etymologic sense, bad air), which emanates from the soil. The simultaneous sudden attack of great numbers under the most diverse surroundings admits of explanation in no other way. But the precise nature of the morbific agent is still unknown. The similarity of epidemic dysentery to malaria would indicate the existence of a low form of vegetable life, a schizomycete, as the direct cause of the disease. But the proof of the presence of a specific parasite or germ is still lacking, and though its speedy disclosure by means of the solid-culture soils may be confidently predicted, it cannot, in the light of existing knowledge, be declared as yet.

Especial difficulty is encountered in the study of micro-organisms in diseases of the alimentary canal because of the myriad variety in enormous numbers found in healthy stools. Decomposition and fermentation both begin in the large intestine, so that the feces swarm with the bacteria and torulæ productive of these processes. Woodward declares that his own observations have satisfied him that "a large part of the substance of the normal human feces is made up of these low forms in numbers which must be estimated by hundreds of millions in the feces of each day," bacteria, micrococci, and torulæ being found "floating in countless multitudes along with fragments of partly-digested muscular fibres and other débris from the food;" but while the torulæ are increased, the other micro-organisms, bacteria, etc., do not appear to be more numerous in the stools of dysentery than in healthy feces.

The doctrine that dysentery depends upon parasites is very old in medicine, and included animal as well as vegetable growths. Langius (1659) declared that swarms of worms could be found in dysenteric stools, and Nyander (1760) went so far as to call dysentery a scabies intestinorum interna; which extravagant conception would have speedily met with merited oblivion had not his preceptor, the great Linnæus, incorporated the Acarus dysenteriæ into his Systema Naturæ. Sydenham about this time (1670) expressed a much clearer conviction of the cause of the disease when he spoke of "particles mixed with the atmosphere which war against health and which determine epidemic constitutions."

Baly (1849) first proclaimed the idea of a vegetable fungus, similar to that described by Brittan and Swayne in cholera, as the parasite of the disease; and Salisbury (1865) described algoid cells and species of confervæ as occurring abundantly in all well-marked cases. Klebs (1867) found spore-heaps and rod-like bacteria in the stools of dysentery as in cholera, but maintained that those of dysentery were larger and thinner than those of cholera. Hallier (1869) maintained that although there was no morphological difference in the micro-organisms of the stools of dysentery, typhoid fever, and cholera, he was able by culture-experiments to develop the micrococcus of dysentery into a special fungus, which he called Leïosporium dysentericum. Busch (1868) demonstrated nests and colonies of micrococci, as well as mycelium, in the villi and among the glands of the mucous and submucous tissues in the cases of dysentery from Mexico which he examined, but Heubner (1870) was able to disclose them in equal numbers in preserved preparations or fresh contents of healthy intestines. Dyer⁴ (1870) believes that the parasites constituting the mildew or sweat which forms a viscous pellicle upon fruit is the agent which directly produces and propagates the disease. Mere immaturity of fruit gives rise only to diarrhoea. This parasite occurs in some years more than others, which accounts for the irregularity of occurrence of the disease. He avers that it is only necessary to clean fruit, more especially plums, to prevent the disease. This suggestion merits place only as a curiosity in the history of the mycology of dysentery.

⁴ Journal f. Kinderkrankheiten, No. 317.

More important are the results of the experiments of Rajewski (1875), who found the lymph-spaces filled with bacteria, and who was able to produce a diphtheritic exudation upon the surface and in the substance of the mucous membrane of the colon by the injection of fluids impregnated with bacteria into the bowels or blood of rabbits; but this result was only obtained when the mucous membrane had been previously irritated or brought into a catarrhal state by the introduction of dilute solutions of ammonia. It remains for subsequent investigation to confirm these highly significant conclusions, which, when properly interpreted, may explain the action of the predisposing and exciting causes of the disease. Rajewski's bacteria, it is needless to state, were simply the bacteria of common putrefaction. Lastly, Prior (1883) describes a micrococcus as the special micro-organism of dysentery, and Koch (1883), in prosecuting his studies of cholera in Egypt, remarks incidentally upon a special bacillus which he encountered in the intestinal canal in dysentery, though he is as yet by no means prepared to ascribe to it pathogenetic properties.

The question of contagion hinges upon the specificness of the disease, and cannot be definitely determined until this problem is finally solved. The old writers believed in the contagion of dysentery. Helidæus declared that he "had often seen it communicated by the use of clyster-pipes previously used in the treatment of those suffering with the disease, and not properly cleaned;" and Horstius and Hildanus speak of the communicability of the disease from the latrines contaminated by dysenteric excreta. Van Swieten maintained that washerwomen contract it, and that physicians and nurses might be affected. Degner saw the disease spread from street to street in Nimeguen, while every one who came in contact with the disease became affected. Pringle observed it spread from tent to tent in the same way; and Tissot went so far as to declare, "Sil ya une maladie veritablement contagieuse c'est celle ci." Ziemssen believed that the disease is only contagious when the element of crowd-poisoning is superadded; and Heubner states that trustworthy army surgeons in the Franco-Prussian War frequently saw infection occur when many severe cases were heaped together in a small space. Under these circumstances thorough disinfection of the privies checked the spread of the disease. But it was the universal testimony of these surgeons, as also of our own surgeons of the Civil War, that the disease was never transported to the civil population by any of the tens of thousands of cases on their return to their homes.

By most modern writers dysentery is given a place, in respect to contagion, between the exanthematous maladies, typhus and scarlatina, which are without doubt contagious, and the purely miasmatic diseases, malarial and yellow fevers, which are without doubt not contagious. Dysentery is ranked with typhoid fever, which is contagious, not by contact with the body, but with the discharges. It is not a question in dysentery of epithelial drift or pulmonary exhalations, but of ingestion or reception of the dejecta of the disease. By this observation it is intended to convey the impression that dysentery, like typhoid fever, is mostly spread in this way, but the reverse may be true; it may be spread, like yellow fever and malaria, by poisons in the air. But dysentery, as has been repeatedly remarked, is only a clinical expression of a disease which may be caused in many ways; and among these causes, least potent perhaps, but present nevertheless, is contagion. For, not to mention the epidemics which were undoubtedly spread in this way, as among the Allies at Valmy in 1792, among the French in Poland in 1807, and in the hospital at Metz in 1870, dysentery has been directly communicated by the use of clysters, bed-pans, and privies in a most unmistakable way.

According to Eichhorst, the poison of dysentery is endowed with extraordinary persistence of duration or tenacity of life in the stools; for "observations are recorded where dysenteric stools have been emptied into privies, and individuals employed to clean them out after the lapse of ten years have been infected with the disease. These observations go to prove, of this as of other similar affections (typhoid fever), that the virus or microbe of the disease finds its most favorable nidus in vaults, cesspools, sewers, etc. When the poison is exposed to the air it is much more speedily destroyed, but is in the mean time of course a possible conveyer of the disease." Fayrer quotes from an anonymous writer, "whose views are as remarkable for their force as for their originality," the rather extravagant assertion that "if human excrement be not exposed to the air there can be no dysentery."

Knoewenagel has recently⁵ opened up a new series of reflections in his suggestion of a possible direct infection of the large intestine per rectum, where the disease usually begins and is mostly best expressed. He calls attention to the fact that people who suffer with constipation indulge in longer sessions at stools and induce in straining efforts a degree of relaxation of the rectal mucosa. The mucous membrane at its orifice may become at the same time abraded by hardened fecal masses, to leave open surfaces or crevices upon which germs may lodge. Moreover, aspiration follows the efforts at expulsion, and the air with its particles is drawn directly into the rectum, thus affording all the conditions for immediate or direct infection.

⁵ Schmidt's Jahrbucher, Sept. 25, 1882.

At any rate, it must be admitted that the evidence in favor of contagion is in some cases too strong to be ignored. A single instance may suffice for illustration: Flügel reports that the towns of Nordhaben and Reichenbach, containing together twenty-two hundred inhabitants, were visited by dysentery in 1873, when nearly four hundred people were attacked. The visit of a relative carried the disease from Reichenbach to the daughter of an innkeeper at Tauchnitz, and from this house the disease spread over the whole place, so that in a short time more than one hundred people fell ill. Four to six, sometimes as many as eleven, members of one family were successively or simultaneously affected. The use of the same bed was the surest means of contagion.

The duration of the poison was proven in an exquisite case, which is, however, not entirely free from objection: Two children of an officer were severely affected in September and October, 1872. In January, 1873, the house was vacated and occupied by a successor in office, whereupon in April, six months after dysentery had disappeared from the place, the wife and child of the second officer were affected with the disease.

To sum up the etiology of dysentery in a few words, it may be said that few chapters in medicine are so thoroughly unsatisfactory, as the prospect of reconciling the accumulated discordant facts is very discouraging. Because of the singular uniformity in the symptoms and lesions the temptation is strong to look for a common cause, and to ascribe all cases to this cause, explaining differences by degree rather than by kind. Such a view would find solid support in the assumption of a specific germ, and would ally dysentery with typhoid fever, a disease which has likewise, in all cases, uniform symptoms and lesions, and which prevails in both sporadic and epidemic form. The advocates of this view would fix the poison of the disease in the air and alimentary canal (but not in the blood), and explain the existence of individual cases, as well as the prevalence of epidemics, by meteorological conditions as affecting the growth or dissemination of specific germs. Nor would the adoption of this view exclude the possibility of producing the catarrhal (sporadic) cases by many kinds of noxious germs, including those of common putrefaction. Hot air and wet air are notorious bearers and breeders of germs, and the law of gravity keeps them near the surface of the earth—conditions which coincide with the prevalence of the disease in the tropics and among individuals (soldiers) who sleep upon the ground. If the contagion of the disease be admitted, the existence of a contagium animatum is implied at once, for no chemical poison has the power of propagation.

But the germ of dysentery has not been found as yet, and until it has been found, cultivated in suitable soil, and inoculated to produce the disease, the evidence of its existence remains merely presumptive.

So that at the present time dysentery must be regarded as a malady which stands in closer relation to, or finds a better analogue in, cholera than typhoid fever; for cholera is a disease which has the same geography, has likewise nearly uniform symptoms and lesions, so far as it leaves any, and certainly has two distinct forms of origin—one clearly specific, cholera Asiatica, and the other catarrhal, cholera morbus.

PATHOLOGY.—Dysentery is a local malady, but, like every local malady if sufficiently severe, it may show constitutional effects. It is usually gradually ushered in from a lighter form of gastro-intestinal catarrh. After a stage of incubation which lasts from a few hours to a few days symptoms of dyspepsia and diarrhoea set in or increase, attended with anorexia, heartburn, nausea, eructation or borborygmi, pain in the abdomen, and copious fluid discharges. Hereupon ensue the pains and the discharges characteristic of the disease. Violent griping and colicky pains (tormina) traverse the abdomen, with sickening sensations of depression. The desire of evacuation of the bowels (tenesmus) becomes intense and more or less constant, and the discharge itself is attended with little or no relief. At the same time the region of the rectum, intensely inflamed, is the seat of intolerable burning pain, which becomes excruciating with the introduction of a speculum or the finger.

The discharges may be copious, dark-brown, thin, and highly offensive (bilious dysentery), may contain occasional hard round fecal casts of intestinal sacculi (scybalæ), or may become more and more scant, until with the most violent efforts only the minutest quantity is extruded of mucus, generally streaked or tinged with blood (rose mucus) like the rusty sputum of pneumonia. Later, all effort at emptying the alimentary canal may be futile (dysenteria sicca), or the mucus may be pure or commingled with pus to remain perfectly colorless (dysenteria alba), or with blood in larger quantity (dysenteria rubra). In other cases, or at other periods in the same case, the discharges consist of fleshy masses composed of inspissated mucus or pus, blood, and tissue-débris (lotura carnea). Sometimes, though rarely, the discharges consist of pure blood, but oftener of a copious turbid fluid, which on standing separates into a clear upper layer of serum and a sediment of disintegrated lotura carnea. Or, lastly, the sediment is composed of small round vitreous masses, evidently swollen by maceration to look like sago-grains, which have been erroneously supposed to represent the liberated contents of the intestinal follicles.

The general condition of the patient suffers correspondingly. There may be fever or there may be none throughout the whole course of the disease, but the pain and discharges quickly exhaust the strength of the patient, and in severe or long-continued cases lead to emaciation and profound prostration.

The skin is hot and dry; the tongue is heavily coated; the face wears an anxious expression. The abdomen is tumid with gases, or in more advanced cases sunken, discolored, and tender, especially in the course of the colon, whose thickened walls may often be felt beneath the emaciated surface. The anus is spasmodically constricted, or in the worst cases paralyzed, patulous, and livid or blue. Prolapse of the rectum is common in children, and excoriation of the perineum by the acrid discharges is not infrequent.

Finally, a typhoid state may set in or a pyæmia occur, when the discharges may become involuntary or unconscious, and brain symptoms—insomnia, stupor, delirium, and coma—supervene; or the patient may linger long enough to perish by simple exhaustion or marasmus.

Under favorable hygiene the great majority of cases of catarrhal dysentery recover without special treatment in the course of from three to ten days, but specific dysentery has no definite duration and but little tendency to spontaneous cure. The worst cases are often quickly controlled by appropriate interference, and the most surprising results may be sometimes obtained in cases of even years' duration. On the other hand, a certain percentage of cases is characterized by a defiance to every kind of treatment, including the last resort, a change of climate.

An acute case of catarrhal dysentery generally subsides without lesions, and the natural duration of the attack may be much abbreviated by proper treatment. Specific or epidemic dysentery lasts from two to four weeks, or, becoming chronic, continues for years or for life, with exacerbations and remissions.

Various complications are liable to occur in the course of the disease. Three deserve especial mention—viz. affection of the joints (rheumatism), paralysis, and abscess of the liver. Perforation and peritonitis, always possibilities, and deformities of the colon, thickenings, and constrictions, are not infrequently left.

MORBID ANATOMY.—The lesions of dysentery are the ordinary signs of inflammation of a mucous membrane and its subjacent structures. They do not differ in any essential way from those of any mucous surface in a state of inflammation, the minor variations being due to differences in the anatomy and physiology of the part affected. Thus, a description of the pathological process in inflammation of the pharynx, bronchi, or uterus would answer upon the post-mortem table for the same process in the large intestine, and the finer microscopic lesions could be differentiated in any case only by the histology of the part affected.