§ 64. Dysenteric fevers; dysentery.

Authors have made a mistake in classing those fevers among chronic diseases. The dysenteric fever ought to be considered an acute disease for this reason, that it may be either endemic or epidemic, and, whenever it appears, has either one or the other of those two forms; that it generally depends upon cosmic and telluric, or atmospheric influences of some kind, and that its outbreak is favoured by errors in diet. Moreover, the disease is characterized by a sort of catarrhal irritation in the mucous membranes of the intestines, and especially the large gut, which, like the irritation in the bronchi, may assume an inflammatory character and occasion a sort of erethic fever which accompanies every inflammatory irritation of the mucous membranes. A dysenteric fever might also be characteristically designated as a febrile catarrh or rheumatism of the large intestines.

Diagnosis: constant urging, tenesmus, with violent cutting colic, without any evacuation of faeces, properly so called; the patient merely discharges mucus and blood, and complains of fever. These are constant symptoms. This shows that the disease is not characterized by diarrhoea, but by constipation, and that dysentery and diarrhoea are, so to say, opposite diseases. In diarrhoea we have discharge of decayed contents of the bowels; in dysentery those contents are retained. Diarrhoea frequently gets well of itself; dysentery very seldom. If feculent substances are again discharged from the bowels, and the pains and fever abate, then the dysenteric patient may be said to be recovering (Hufeland). If the disease should set in with great violence, which is sometimes the case in young, vigorous, or sensitive individuals - in which case it may assume the form of a synochal fever-the precursory stage is either entirely wanting or is very short. The precursory stage is mostly met in torpid, phlegmatic individuals, or when the disease is sporadic; in such cases the fever has the erethic form.

If there be no precursory stage, the course of the disease is short; if a precursory stage exist, the disease has a long run, and frequently passes in o a chronic dysentery. The precursory symptoms are: want of appetite, pressure in the region of the stomach and dull colic, loathing, nausea, inclination to vomit, dirty coating of the tongue, bad taste, flatulency, diarrhoea; general laxness and debility; malaise, restless sleep; drawing in the limbs, increased sensitiveness to cold air, shiverings, slight chills, accelerated pulse.

The first commencement of the disease is a cessation of the bilious stools, and setting in of an unsuccessful urging, resulting simply in the discharge of some mucus (dysenteria alba). Little by little the most violent cutting and colic are experienced in the umbilical region, with sensation of burning, thence extending over the whole abdomen, and immediately preceding every succeeding evacuation. As the irritation increases, the slimy evacuations appear mixed with blood. The most intensely painful symptom now is the tenesmus, a sensation as if the bowels would protrude, occasioning a constant renewal of the stools, which often become excessive in twenty-four hours, and spread a peculiar smell. The fever is proportionate to the degree and violence of the disease, and generally does not make its appearance until the permanent symptoms of dysentery have all set in. That fever is a continua remittens, having in most cases a rheumatic, catarrhal, or bilious character; it commences with a succession of moderate chills, followed by moderate heat. The exacerbation generally takes place in the evening, and is accompanied with a perceptible aggravation of the local symptoms.

§ 65. The disease is occasioned by various remote causes, the principal being the suppression of some kind of cutaneous action, with increase of acrid bile. This is the reason why dysentery prevails almost exclusively towards the end of summer, in the months of August and September, when the days are very hot and the nights very cool. At that season of the year dysentery is almost always epidemic. The disease is endemic in low, damp, marshy regions, where intermittent fevers are likewise prevalent; in such districts dysentery occurs almost every year. In epidemic dysentery the putrid emanations from the stools frequently develope a contagium by means of which the disease spreads rapidly and over a large extent of country.

Other exciting causes are: unripe, acrid, watery fruit; vegetables covered with mildew; corrosive poisons, worms, haemorrhoidal congestions, metastasis, difficult dentition. The-prevailing type or character of disease becomes easily ingrafted upon the dysentery, and may convert it into a catarrhal, rheumatic, gastric, bilious, or typhoid dysentery, although every one of those varieties may likewise be occasioned by the individuality and constitution of the patient. Children and females are principally affected by that disease.

Chronic affections are sometimes roused by an attack of dysentery, and may in their turn complicate the disease, and make the prognosis more or less doubtful; although the termination of the disease does not depend exclusively upon the complication, but also upon the greater or lesser intensity of the dysentery itself. As the disease increases, inflammation supervenes, an excessive quantity of putrid bilious substances is expelled from the system, and the patient is extremely debilitated. All these symptoms may occasion death if the patient be not carefully treated, and the most unfavourable prognosis has to be given if a sudden cessation of the intense pain, sunken countenance, coldness of the extremities, a small intermittent pulse, fetid evacuations, which the patient passes without consciousness, indicate the setting in of mortification.

The post-mortem examination shows that the disease is seated in the mucous membrane of the large intestines. This membrane is swollen, red and injected, softened (the softened parts being red and bleeding); a serous exudation is perceived in the shape of a fine miliary vesicular eruption, which results in the scaling off of the epithelium of the inner walls of the large intestine. These appearances characterize the lower degrees of dysentery; in the higher degrees larger surfaces are affected, and the mucous membrane is covered with a dingy grey, glutinous exudation, accompanied with prominences which are formed by a copious serous infiltration of the submucous cellular tissue. This degenerative process increases until a dark red or black brown sanguineous exudation has resulted from it, which, in the highest form of the disease, becomes a black, friable, tearable, and almost carbonized mass.