temperature, by the speedy occurrence of multiple abscesses in distant
organs, venous thromboses, affections of the serous membranes,
pleuritis, pericarditis, and embolic pneumonia. Gangrene of the
intestine, which may occur as early as the third day of the disease
(Nägele), is evidenced by the signs of general collapse.
{805} COMPLICATIONS AND SEQUELÆ.--The lighter cases of dysentery, as
well as most of the grave cases, run their entire course without
complication, and often without sequelæ. But a certain percentage of
cases is attended with complications on the part of the joints
(rheumatism), of the nervous system (paralysis), and on the part of the
liver and the kidneys.
Arthritis, when it occurs, shows itself, as a rule, in the second week
of the disease (Eichhorst), or after the disease has run its course,
during the period of convalescence (Huelte). That it is not a mere
coincidence is evidenced by the fact that it is present in a large
number of cases in certain epidemics, while it is not present
independently of dysentery. Thus, Braun of Stannenheim saw in the two
epidemics of 1833-34 more than forty cases of rheumatism, and Huelte
reports ten cases observed by himself in the epidemic at Montargis in
1854. Certain epidemics are distinguished by the rarity of this
complication, while most are marked by its absence altogether. In the
epidemic at Rahden (1872), 400 cases among 3800 inhabitants, Rapmund
saw inflammation of the joints set in only six times; and the entire
absence or extreme rarity of it in later epidemics have led most
physicians to deny any connection between the diseases, or to regard
the joint affection as incident to a complicating scorbutus or
neuralgia. All authors who admit it describe the knee-joint as being
the most frequent seat of the affection, but acknowledge that it is
mostly polyarticular; while there is much difference of opinion whether
it ever presents the general signs of true rheumatism--pyrexia,
diaphoresis, or its complications on the part of the heart. Huelte
maintains that it does not, and that it is allied to gonorrhoeal
rheumatism in this respect, while Eichhorst states that it may not only
show all these signs, but may be followed in exceptional cases by
suppuration and ankylosis. It usually lasts four to six weeks, but
neither its occurrence nor its severity stands in any relation to the
intensity of the attack of dysentery. It is probably to be regarded as
a manifestation of a light pyæmia or septicæmia, as it is a frequent
manifestation of this condition in or after scarlatina, puerperal
fever, and the septic fevers of surgery.
Paralysis has been observed to occur after dysentery ever since the
days of Galen, and, disregarding the observations of ancient and of the
older periods of modern times, we find occasional records of cases in
our own days. Leyden,[6] in reporting a case of paresis and rheumatic
pains following an attack of dysentery, says that although
post-dysenteric paralysis is now rarely mentioned, it was frequent in
the older reports, and claims it as an admitted fact that it occurs not
at all infrequently now. Joseph Frank quotes some observations of this
kind, and refers especially to the dissertation of Fabricius.[7] These
paralyses, Fabricius observes, have been seen after the premature
suppression of malignant epidemics of dysentery by opiates and
astringents. Observations were afterward recorded by Graves in which
paralysis occurred after colics and inflammation of the intestines; and
English veterinary surgeons mention the fact that paralytic weakness of
the posterior extremities of horses and cattle follow attacks of
intestinal inflammation. The paralysis, when it occurs, is usually
confined to the lower extremities, but may extend to {806} and involve
the upper extremities, by preference in the form of paralysis
transversa (opposite arm and leg). Brown-Séquard attributes it to
reflex contraction of the blood-vessels; Jaccoud, to exhaustion of the
nerve-centres; and Röser, to the contact of the inflamed transverse
colon with the solar plexus. Remak first suggested the idea of an
ascending neuritis--a view which would seem to be corroborated by the
paralysis observed after the experiments, by Lewisson, of crushing the
uterus, kidneys, bladder, or loop of intestine, and which finds
additional support, as Leyden remarks, in the length of time which
lapses before it appears. Landouzy[8] says that Finger found diffuse
myelitis in a patient affected with paralysis supervening upon cancer
of the intestine, and that Delioux and Savignac saw spots of softening
in the cervical and lumbar region of the cord in the case of a man
affected with post-dysenteric paralysis. Weir Mitchell suggests the
possibility of other factors--long marches, malaria, bad diet, and
injuries to the spine--in the genesis of the cases, mostly paraplegias,
observed by him; and Woodward calls attention to lead-poisoning (as by
treatment) in explanation of a certain number of cases.
[Footnote 6: "On Reflex Paralysis," _Volkmann's Sammlungen_.]
[Footnote 7: _Paralysis seu hemiplegia transversa resolutionem brachii
unius et pedis alterius exhibet_, Helmstedt, 1750.]
[Footnote 8: _Des Paralysies dans les Maladies aigues_.]
Abscess of the liver gives rise to few distinctive symptoms, and is
mostly recognized or suspected, in the absence of positive signs, by
the persistence or obstinacy of the dysentery. The ease and impunity
with which aspiration may be performed in its recognition justifies the
use of it in every doubtful case.
Regarding complications on the part of the kidneys, Zimmerman
recognizes four classes of cases: (1) mild cases, showing no albumen
and no casts; (2) severe, long-continued cases, with putrid stools,
status nervosus, and collapse, showing albumen; (3) cases commencing
with nervous symptoms, paralysis, scanty urine, showing kidneys filled
with exudation-cells and detritus; and (4) cases of speedy renal
complication and death. To these may be added the cases of protracted
chronic dysentery with long-continued suppuration, entailing the
possibility, of really rare actual occurrence, of amyloid degeneration
and chronic parenchymatous change (Bartels).
Dysentery may be further complicated by parotitis; by venous thrombosis
(phlegmasia dolens); by diphtheritic deposits on other mucous surfaces,
which Virchow declares to be exceedingly rare; and by hydrops, which is
oftener a concomitant of the period of convalescence.
Besides the deformities of the colon, which may ensue as a consequence
of ulceration or peritonitis, a long attack of dysentery is apt to
leave a hyperæsthetic or non-resistant state of the mucous surface, so
that every imprudence in exposure or in diet begets an intestinal
catarrh or a relapse of the disease.
DIAGNOSIS.--When dysentery presents itself with its whole train of
symptoms the recognition of the disease is very easy. The tormina and
tenesmus, the peculiar discharges, the rapid reduction of strength,
leave no doubt as to the nature of the affection. The prevalence of an
epidemic of the disease will often establish the character of a case
even when all the signs are not present or when anomalies occur.
Embarrassment in diagnosis only attends the recognition of catarrhal or
isolated cases, and in these cases there may be a doubt as between
dysentery and {807} diarrhoea--if such a symptom can be called a
disease--or typhoid fever, cholera, or some purely local affection of
the rectum, cancer, hemorrhoids, etc. In children difficulty of
diagnosis may arise as between dysentery and intussusception.
Dysentery is differentiated from that lighter form of intestinal
catarrh whose main symptom is diarrhoea by the presence of tenesmus in
dysentery, as well as by its mucous, muco-purulent, diphtheritic, and
bloody discharges. Dysentery lasts longer than diarrhoea as a rule, and
does not yield so readily to treatment.
Typhoid fever shows from the start brain symptoms, which are absent
from dysentery; has a typical temperature-curve, whereas there may be
no fever in dysentery, or, if any, of irregular remittent type; is
often prefaced by epistaxis and attended with bronchitis, both of which
are absent in dysentery; and exhibits ochre-colored pea-soup stools,
altogether different from those of dysentery.
Cholera morbus distinguishes itself from dysentery by its sudden onset,
its profuse vomiting and discharges, its violent cramps, and the speedy
collapse.
Cancer of the rectum can be usually felt, and hemorrhoids can be always
seen, so that no difficulty should be experienced in the recognition of
these cases.
Intussusception occurs mostly in children, and has, in common with
dysentery, vomiting, mucous or bloody stools, colic, tenesmus, nervous
unrest, and prostration, so that a differential diagnosis may be
impossible for a few days. The more strict localization of an
intussusception, which may sometimes be felt as a sausage-like mass,
most frequently in the right ileum and hypochondrium, the greater
frequency and persistency of the vomiting and pain, the presence
visibly or palpably of the invaginated gut at the anus or rectum, soon
enable the careful examiner to recognize the case.
PROGNOSIS.--The prognosis of dysentery varies between extremes. Some
cases are so mild as to merit the remark of Sydenham concerning certain
cases of scarlet fever: "Vix nomen morbi merebantur." They terminate of
themselves under favorable hygiene without especial treatment. On the
other hand, no known disease has a more frightful mortality than
dysentery in some of its epidemics, especially in army-life. It was
this class of cases which Trousseau had in mind when he called
dysentery the most murderous of all diseases. Sixty to eighty may be
the appalling percentage of death in these cases.
Under favorable surroundings the average mortality of dysentery amounts
to 5-10 per cent., but is much influenced by the age and the general
condition of the patient, as well as by the complications which occur
in its course. Thus, Sydenham said of it over two hundred years ago,
"It is not infrequently fatal to adults, and still more so to old men,
but is nevertheless exceedingly harmless to infants, who will bear it
for months together without suffering, provided only Nature be left to
herself." But dysentery is by no means always harmless to infants, for
in some epidemics this period of life has been visited with the
greatest severity. Thus, Pfeilstücker reports of Würtemberg (1873-74)
that the greatest mortality, 39 per cent., occurred at the age of one
to seven years, and the least, 4 per cent., at the age of thirty-one to
fifty years; {808} and Oesterlen says of England that dysentery causes
20 per cent. of deaths from all causes in the first year of life.
Nor does the prevalence of a greater number of cases necessarily imply
a heavier mortality. For Bianchi reports of Rome that cases of
dysentery constituted but 2.28 per cent. of all the admissions into the
Ospedale di San Spirito in 1873, while in 1874 the percentage increased
to 3.68; yet the mortality of 1873 was 17.02 per cent., while that of
1874 was but 9.09 per cent.
Complications on the part of the nervous system, the status typhosus,
pyæmia, and great prostration, necessarily render the prognosis grave,
yet even these cases are not necessarily fatal. Thus, Jules Aron
reports from the epidemic at Joigny (1876) a case of recovery after
complete paralysis of the sphincter ani. The recognition and discharge
of an hepatic abscess relieves the patient from the dangers of this
complication. Peritonitis alarmingly aggravates the prognosis, and
perforation is almost of necessity fatal.
PROPHYLAXIS.--The improved sanitation of modern times has already
diminished the frequency and mitigated the severity of epidemics of
dysentery; and this fact, which is only an accidental observation as it
were, gives the clue to the means of its further prevention.
The selection of proper sites for camping-grounds, barracks, and
hospitals, the prevention of overcrowding in tenement-houses, ships,
and jails, the regulation of sewage, the care for the food and drink,
the observation of the strictest cleanliness by authoritative
control,--all these are general measures which suggest themselves in
the prophylaxis of this or any disease.
In the management of individual cases the first precaution is to
prevent the dissemination of the disease. Whether it be really
contagious or not, every case should be managed, as Bamberger suggests,
as though it were contagious; and this protection of others secures for
the individual patient the most favorable hygiene.
The bedding must be frequently changed; the windows kept open to secure
free ventilation, which, in the light of existing knowledge, is the
only true disinfectant; and all the furniture of the sick-room,
especially including the receptacles for the discharges, must be kept
perfectly clean. For this purpose the best purifier is very hot water.
The temperature of the sick-chamber, if it be subject to regulation,
should never be allowed to sink below or rise above 65-70° F.
The drinking-water should be secured, during an epidemic, from the
purest possible source, and if good drinking-water cannot be had, what
there is should be thoroughly boiled.
The discharges should properly be mixed with sawdust or some
combustible substance and burned, or if this be impracticable should be
buried in the soil a few feet below the surface, and not emptied into
water-closets or privy-vaults used by others.
Such articles of food should be abjured as have a tendency to produce
intestinal catarrh. So unripe fruits, vegetables which readily undergo
fermentation--in short, all indigestible substances--should stand under
ban. But no prohibition should be put upon ripe fruits or simple
nutritious food of any kind.
Lastly, individuals should protect themselves from catching cold. The
{809} researches of Pasteur have disclosed the fact that certain germs
of disease will grow and multiply in the body of an animal whose
temperature is reduced, when they would not increase without it.
TREATMENT.--The first requisite in the treatment of an individual case
is perfect rest. Patients with even the lighter forms of catarrhal
dysentery should observe the recumbent posture, and cases of more
serious illness should be put to bed. Rest in bed, an exclusive diet of
milk--which should always have been boiled--and the time of a few days
is sufficient treatment for the mildest cases. Where there is objection
to milk, meat-soups, with or without farinaceous matters, rice, barley,
etc., may take its place.
A case which is somewhat more severe will require perhaps a light
saline laxative--a Seidlitz powder, a dose of Rochelle salts or Epsom
salts in broken doses--or a tablespoonful of castor oil or five to ten
grains of calomel, to effect a cure. For the relief of the pain of the
lighter cases nothing is equal to tincture of opium, of which five to
ten drops every three or four hours in a tablespoonful of camphor-water
acidulated with a few drops of nitric acid will generally suffice; or
Dover's powder in broken doses, one to three grains, with five to
fifteen grains of bismuth or soda, or both, is a good substitute for a
change.
The successful treatment of dysentery in any form depends upon a
recognition of the fact that the disease is local as to its seat, and
is probably specific as to its cause. The anodynes relieve the effects,
but the laxatives remove the cause. Consequently, the most rational
treatment of the severer cases is the irrigation of the large intestine
and the thorough flushing out of its contents. The use of clysters in
the treatment of dysentery dates from the most ancient times, with the
object, however, rather of medicating than washing out the bowel.
O'Beirne (1834) and Hare (1849) were the authors of the irrigation
treatment, which they executed by means of a long tube introduced into
and beyond the sigmoid flexure. Since Hegar has recently shown how the
whole tract of the large intestine can be thoroughly inundated and
flushed with a common funnel and rectal tube, the practice has
continually gained ground, until it is now admitted as the most
valuable method of treatment. H. C. Wood of Philadelphia, and later
Stephen Mackenzie of London, have reported a number of cases in which
irrigation of the bowel with large injections medicated with nitrate of
silver, drachm j-pint j, was attended with the most surprising
results--sometimes but a single injection effecting a cure; and the
writer of this article has reported one case almost in articulo mortis
where complete cure followed the irrigation of the bowel--on three
occasions with three pints of water containing three drachms of common
alum. This case was all the more instructive from the fact that a
relapse had occurred after very striking but only temporary relief had
been obtained with the nitrate of silver, the alum having been
substituted simply on the ground of expense.
Salicylic acid has also been extensively employed in this way with the
best effects, but carbolic acid has been discarded since the reports of
several cases of poisoning have been published. Should it become a
question of the necessity of a parasiticide, the bichloride of mercury
in extremely dilute solution, 1 to 1000, would be the agent par
excellence; but it is probable that the simple flushing of the bowel is
the chief {810} curative agent. The use of alum is not attended with
the dangers which have ensued from the absorption of carbolic acid, and
which might ensue from the bichloride of mercury. The water used in the
injections should always be cold. Ice-water injections alone give at
times the greatest relief. Wenzel uses injections of ice-water in all
recent and acute cases, whether slight or severe--in bad cases every
two hours. He seldom finds it necessary to use opium. The object is to
introduce as much water as possible without producing too much pain.
The large intestine of an adult holds, on an average, six imperial
pints, but in the author's experience not more than three or four pints
can be safely introduced. The patient should lie upon the back or the
left side with the hips elevated and the head low, while the injection
is slowly introduced from a funnel, fountain, or a bulb syringe whose
nozzle is thoroughly anointed with vaseline. In the absence of a
thoroughly competent assistant the operation should be performed by the
physician himself, for the proper use of an irrigating enema is a
practice which requires both judgment and skill. When pain is
experienced, the further influx of the fluid should cease for a few
minutes, when it may be resumed again and again until the largest
possible quantity is introduced. It is impossible to over-estimate the
value of this treatment in cleansing, disinfecting, and constringing
the foul and flabby surface of the whole seat of the disease. As was
said by Hare, "It changes a huge internal into an external abscess, and
enables us to cleanse the bowel of its putrid contents."
Of all the remedies which have been recommended in the relief of
dysentery besides the irrigation method, but one, ipecacuanha, deserves
the name of a specific. This remedy was first introduced into practice
in 1648 by the botanist Piso, who was led to adopt it from the popular
praise he had heard of it while travelling in Brazil. He considered it
the most exquisite gift of nature, and administered it in infusion
according to the Brazilian (subsequently known as the French) method.
Légros made three successive voyages to South America to import
supplies of the drug to France, but neither he nor the French merchant
Grènier, who had brought over more than one hundred and fifty pounds of
it, could secure its general use. Thereupon, Grènier acquainted Adrian
Helvetius, a Dutch physician practising in Paris at the time, with the
wonderful virtues of the Radix dysenterica, who, having experimented
with it first upon patients of the lower classes, was later successful
in curing the Dauphin of France. The further use of it, by permission
of the king, at the Hôtel Dieu, enabled him to secure a monopoly of its
sale and secured for him a grant of a thousand pounds. Grènier hereupon
put in his claim for a division of the profits, and upon the refusal of
Helvetius instituted suit to obtain his rights. Justly indignant at the
loss of his suit, he revealed the secret, and ipecacuanha became common
property at once. Extravagant ideas were now entertained of its value,
but in the extreme reaction which followed every virtue of it was
disavowed, so that the drug came to be almost forgotten. From this
temporary oblivion the remedy was rescued by an English army surgeon,
E. Scott Docker, in 1858, who administered it, in combination with
laudanum, in his regiment, on the island of Mauritius, in all cases and
stages of the disease with such success that out of fifty cases he lost
but one. Although such indiscriminate use and such almost unvaried
success has not attended, and from the nature {811} of different cases
could not attend, its universal employment, there is no doubt of the
inestimable value of the service rendered in the restoration of the
remedy in the treatment of dysentery. Yet over twenty years elapsed
before its author received from his country, at the urgent solicitation
of the Director-General, in recognition of this service, a grant of
four hundred pounds.
Remarkable testimony as to its efficiency soon began to appear.
Ewart[9] recommends ipecacuanha in every form and type of acute
dysentery, as well as in the acute attacks supervening upon chronic
cases. Its advantages are simplicity, safety, comparative certainty,
promptitude of action, decrease of chronic cases and of complications,
especially abscess of the liver, and great reduction of mortality. "It
produces all the benefits that have been ascribed to bloodletting,
without robbing the system of one drop of blood; all the advantages of
mercurial and other purgatives, without their irritating action; all
the good results of antimony and other sudorifics, without their
uncertainty; all the benefits ascribed to opium, without irritating, if
not aggravating or masking, the disease." To the objections urged
against it he replies that the nausea is only temporary and
evanescent--that vomiting is exceptional and of but short duration;
moreover, it permits nourishment and assimilation and produces sleep.
If uncontrollable sickness and vomiting occur, they are probably due to
abscess of the liver, malaria, some other cachexia, Bright's disease,
strumous mesenteric glands, hypertrophy of the spleen, peritonitis, or
extensive sloughing.
[Footnote 9: _Indian Annals Med. Science_, April, 1863.]
Cunningham prefaces the treatment by a sinapism to the epigastrium and
half a drachm of the tincture of opium. Then from one to one and a half
drachms of ipecacuanha are administered in powder. It causes
considerable nausea, and vomiting occurs in one to two hours. During
the nausea copious perspiration breaks out, the pulse becomes fuller,
softer, and less frequent, the tenesmus and abdominal pains cease, and
the patient has no more stools for twelve to twenty-four hours. The
next evacuation is easy, fluid, but free from blood or mucus. Sometimes
the dose of ipecacuanha may require to be repeated.
Malun reports the results of treatment of 436 cases occurring in
twenty-one months. There were only 6 deaths, and in only 1 of these
could the remedy be fairly said to have failed. Under all other plans
of treatment the mortality has varied from 12 to 22.3 per cent.
Mr. Docker says that the mortality of dysentery in the British army
during the ten years that followed the adoption of the ipecacuanha
treatment fell from 11 to 5 per cent.