The disease may begin suddenly without any premonitory symptoms, or after a few days of general malaise, loss of appetite, and irregularity of the bowels, the patient is attacked with abdominal colic and diarrhoea. These symptoms are usually accompanied by chills, vague pains through the body, and fever. The stools, at first abundant and watery, very soon become scanty, mucous, and usually contain blood. Gastric disturbances are present in almost all cases: anorexia, nausea, often vomiting. The principal features of dysentery are the characteristic stools, the abdominal pains, and tenesmus.

1. Stools

The evacuations increase in frequency, occurring from twenty to twenty-seven times during the twenty-four hours. The calls to stool are usually preceded by rumbling and colicky pains, and are followed by straining and tenesmus. While during the first and perhaps the second day of the disease the motions are copious, they soon become scanty. The patient is then able to expel but a small quantity, about a teaspoonful of mucus mixed with blood, after painful efforts. Occasionally a few small pieces of fecal matter are passed. The dejecta occasionally change their character with regard to frequency as well as consistency. Intermissions and exacerbations of the diarrhoea are sometimes observed in the course of the disease. The mucus in the stools is almost always mi with blood. In some cases the dejecta are hemorrhagic, that is, consist of almost pure blood, either red and fluid or dark and coagulated. In dysentery complicated with gangrene the stools are serous, of a dark reddish-brown color, and contain, in addition to finely divided membranous threads, large and thick masses of necrotic tissue of a gray or black color. The gangrenous dejecta have an intensely offensive odor.

In many instances the stool contains no* bile.

Amoebae are almost always found in the dysenteric stools, especially if the lesions are quite extensive. In examining the faeces for amoebae it is well to use some precaution. If possible the examination should be made immediately after the dejecta have been passed. If this be impossible, the stool should be preserved in a clean vessel and kept in a warm place until the examination is made. The amoebae are from 12 to 36 in diameter, and when alive frequently change their shape by contracting some part of their bodies in order to move about. The body of these micro-organisms consists of an outer clear homogeneous substance or ectosarc and an inner highly refractive mass or endosarc. Within the latter are usually found some bacteria, sometimes changed red blood corpuscles, and a few quite large vacuoles. The amoebae, when outside of the intestinal tract, die very quickly, especially if they are kept in a cool place. When dead, these organisms generally show a round or almost round configuration.

(2) Abdominal Pain

Abdominal pains exist with greater or less severity in almost every case. The pains may be experienced continuously, or principally before an evacuation. Most often they are located in the umbilical region and in the left iliac fossa, but sometimes they exist in the right iliac fossa and may then almost simulate an attack of appendicitis. The pains may be so severe that the patient is forced to lie perfectly still for fear of increasing them. Pressure exerted on the large intestine as a rule provokes more or less intense pain. According to Dutrouleau,1 in some very grave cases there is a total absence of colic during the entire course of the disease.

(3) Tenesmus

Rectal tenesmus, consisting at first in painful sensations of pressure and constriction and later in an intense desire to go to stool, is encountered very frequently. In grave cases of dysentery the tenesmus may exist almost uninterruptedly. Off and on the patient succeeds in expelling a small amount of fecal matter or slime or merely gas, and then feels relieved for a short while. Very soon, however, the pains in the anal region return with the same severity. When the tenesmus is very severe it may be accompanied by dysuria or strangury. In this condition the patient presents a pitiable appearance. His straining is frequently agonizing and occasionally accompanied by fainting.

Besides the three cardinal symptoms of dysentery just ribed, other symptoms are often encountered. Fever may be present, especially in the severer form of the disease. It may occur in the form of chills, when the disease is first ushered in. As a rule, the fever is not very high and shows an irregular course. Gastric symptoms are often present. They consist in intense anorexia, nausea, vomiting, and pain in the epigastric region. The general condition is more or less affected according to the severity of the disease. In grave cases prostration is marked, the skin is dry, the features are altered, and the extremities sometimes cold. The pulse is small and rapid. Sometimes cerebral disorders, stupor, drowsiness, even delirium, are encountered.

1 Dutrouleau: " Traite des Maladies des Europeens dans lea pays chauds. "Paris. 1868.

Dutrouleau and others divide cases of acute dysentery into three groups: Cases of a mild character, those of medium intensity, and those of a severe type. In the mild form, there exist only local symptoms which are usually not very intense. In the form of medium intensity, the local symptoms are more accentuated and general symptoms are encountered. In the severe form, there are fever, intense pain, very bloody stools, great prostration, and intolerable tenesmus.