Chronic dysentery develops either after several attacks of the acute form or directly from the first acute attack, which after some periods of improvement persists to a greater or less extent. Cases of chronic dysentery are also divided into three categories:

(1) The Mild Form

The general nutrition is not interfered with. The patients usually complain of slight constipation interrupted by light attacks of diarrhoea. Tenesmus is either entirely absent or present in a very slight degree. Even during the attacks of diarrhoea the passages are, as a rule, not bloody.

(2) Form Of Medium Intensity

Here slight gastric symptoms are present, like anorexia, belching, etc. The general condition is interfered with to a considerable extent. There are almost always periods of intermission and exacerbation of the disease. The patient may have regular movements or be slightly constipated, for a period varying from a week to ten days, but soon diarrhoea appears and lasts for four or five days. The stools are then watery, contain mucus, and occasionally a little blood. Slight colicky pains are present, as well as moderate tenesmus and a sensation of heat or burning in the rectum.

(3) The Severe Form

General nutrition is greatly impaired. The patient becomes emaciated, pronounced gastric symptoms are present: anorexia, a bad taste in the mouth, often nausea, occasionally vomiting. As a rule, there is persistent diarrhoea, and the dejecta present a mucous or muco-sanguineous character. Colicky pains in the abdomen and pronouuced tenesmus are present. In some cases, however, the diarrhoea alternates with short periods of constipation lasting two or three days. The patient usually feels very weak and is obliged to stay abed a great deal of the time.

Course

The course of acute dysentery is very indefinite. Sometimes the disease terminates in recovery in eight to fifteen days; sometimes in one to three months; sometimes again death occurs a few days after the commencement of the disease. Again, a case of dysentery may at first be mild, but later assume a dangerous character, and even terminate fatally. Intermissions and exacerbations are often encountered in this disease. When dysentery becomes chronic its duration varies greatly, often depending upon the severity of each particular case. Thus, it may last five to six months or many years. Even in the chronic form recovery is not entirely impossible.

Complications

The course of the disease is occasionally modified by various complications. Peritonitis often results from an extension of the ulcerative process from the intestinal wall to the peritoneum. Perforation of the intestine may occur in a similar way, and is observed principally in gangrenous dysentery. Sudden death is occasionally observed in such an event. In acute as well as in chronic dysentery severe hemorrhages from the bowel may take place. The loss of blood may be so great even as to cause death. Thrombosis of the femoral artery as well as of the venous sinuses of the brain has been observed by Laveran 1 as a complication of dysentery. A patient of mine with acute dysentery, apparently on the road to improvement, suddenly one day developed a paralysis of the upper and lower right extremities. He later lost con-sciousnes and died about forty-eight hours after the first signs of paralysis. Here most probably thrombosis of some brain vessels took place.

The most frequent complication of dysentery is abscess of the liver. In the majority of instances it is observed in convalescence from acute dysentery or during the evolution of chronic dysentery. The symptoms of the formation of an abscess in the liver are: fever of an irregular character, occasionally chills and pain in the hepatic region which may radiate to the right shoulder. The physical examination often reveals some enlargement of the liver. In the event of a liver abscess opening into the lungs, there is persistent cough and sometimes expectoration of a reddish-brown fluid containing amoebae. Abscess of the liver is more frequently encountered in tropical regions than here. The course of such an abscess is very irregular. Sometimes it progresses rapidly, at other times it shows periods of intermissions and exacerbations. The large abscesses of the liver, if not operated upon, usually terminate in death. Rarely recovery may follow the opening of the abscess into a neighboring organ.

1 Laveran: "De la phlebite, de la thrombose et des paralysies comme complications de la dysenteric " Archives de Medecine militaire, 1885.