Dysentery.

Synonyms.—Flux; Bloody Flux; Recto-Colitis.

Definition.—An acute and sometimes chronic, infectious disease of the large intestine, characterized, pathologically, by inflammation and ulceration of the mucous membrane; clinically, by frequent, small, painful, mucous or bloody stools, attended by great tenesmus and almost constant desire to evacuate the bowels, a fever of more or less severity, great prostration, and quite rapid emaciation.

History.—Dysentery is one of the oldest and most widely distributed of diseases which the physician is called upon to treat. That it is a very ancient disease is proven by the fact that it was well known to, and accurately described by, Hippocrates, Galen, Herodotus, and many other early writers. As evidence of its universal distribution, we have yet to learn of any part of the inhabitable globe which has not been visited by this unwelcome guest.

Although usually regarded as a disease of the temperate or tropical zones, Greenland, Iceland, Norway, Sweden, and Siberia have paid tribute to dysentery.

Of this disease Sodre says, "There is no country, and no extensive district in any country, from the equator to the poles, in which dysentery has not been observed in the sporadic, endemic, or epidemic form." Great epidemics, attended by a high death-rate, have made dysentery one of the most dreaded lesions which affect humanity. Thus the epidemic which visited Sweden in 1857 claimed thirty-seven thousand victims, of whom ten thousand died; and in 1897, Japan was visited by an epidemic in which ninety thousand cases occurred, with twenty thousand deaths.

It prevails to an alarming extent in army and camp life, and Woodward, in speaking of its ravages during the War of the Rebellion, gives the record of cases occurring in both armies as two hundred and fifty-nine thousand and seventy-one cases of acute, and twenty-eight thousand four hundred fifty-one cases of chronic dysentery. This great number can, in all probability, be duplicated in all the great wars which have afflicted the human race during the centuries of warfare. Fortunately, with the observance of better sanitary measures, the disease is becoming rarer, and the presence of dysentery does not now produce the alarm which it once occasioned.

Varieties.—The division of the older writers into acute and chronic is, I believe, better than the more modern division of catarrhal, amebic, and diphtheritic; for, as Sodre well says, "Dysentery is one, and one only, whether it be considered from an etiological, clinical, or anatomical point of view, and the latter division only tends to confuse the student. They are simply different phases or symptoms of the one disease."

Etiology.—Among the predisposing causes are the following:

Season ranks first, for by far the greatest number of cases occur during the late summer or early autumn months. Sudden atmospheric changes, where the days are hot but the nights cool, are conditions which favor dysentery. Climate also predisposes to the disease; for while we find dysentery from the poles to the equator, it becomes far more frequent, and finally endemic as we approach the equator.

Age.—While no age is exempt, it is more frequently found in adults. Males are more frequently affected owing to greater exposure.

Unhygienic surroundings predispose to the lesion, as shown by the frequent outbreaks in public institutions where sanitary measures are neglected, and in army and navy penal institutions.

Catarrhal conditions of the intestinal canal, as well as certain infectious diseases—such as typhoid fever, typhus fever, and, in fact, the eruptive fevers in general—predispose to dysentery.

While these various conditions favor the development of dysentery, it is not likely that any one, or all combined, ever produce the disease. They simply prepare a soil favorable to the development of the germ or toxin which gives rise to the disease.

The tendency of the disease to appear in epidemic form is one of the best evidences of its infectious character. It is true that we meet with sporadic cases, yet this may be said of a number of infectious diseases.

The Shiga bacillus, or bacillus dysenterieae, is regarded by many as the distinctive pathogenic agent, while others believe it due to a combination rather than an association of micro-organisms, a number of which constantly infect the intestinal canal. Bertrand, one of the most prominent advocates of this theory, says, "Dysenteric infection is poly-bacterial, not specific." The most generally accepted specific germ is that described by Lamb in 1859, and Losch in 1875, as ameba coli. The germ or toxin is most likely disseminated through drinking water.

Pathology.—The tissue changes in dysentery are quite varied, depending upon the severity and character of the attack. In the acute catarrhal form, especially if sporadic, the inflammation is nearly always confined to the colon and rectum, though in rare cases the ileum is involved.

The mucous membrane becomes hyperemic, swollen, and more or less injected, and bright-red in color, changing to a dusky hue, with increase of sepsis. The whole surface is covered with a tenacious, jelly-like, bloody mucus, often mixed with more or less purulent material. The solitary glands become swollen, and vary in size from that of a radish-seed to that of a pea. Necrosis may result, followed by ulceration. The submucosa may be invaded, becoming swollen and infiltrated, and, in the severer grade, extend to the serous and muscular coats.

In some cases, more frequently in children, the follicles bear the force of the attack, and the disease is known as follicular dysentery. Here there is infiltration, followed by necrosis and ulceration. These ulcers may be small and separate, or several may coalesce, giving rise to ugly, ragged, and irregular ulcerative patches. In the graver forms, usually the epidemic, pseudo-membranous patches form; hence the term, diphtheritic dysentery.

There may be extremes of tissue change, from the thin, slight, yellowish membrane, occupying circumscribed areas of the mucous membrane, to the most severe types, where a thick exudate of fibrin, pus, and blood invades the submucosa and serous coats. Necrosis taking place, this membrane sloughs away, leaving large, irregular ulcers. Where this is extensive, there is evidence of great sepsis, and death often results. Where healing follows, there is apt to be contraction of the ulcers, followed by more or less stricture.

In hot climates, where dysentery assumes the graver forms, it is known as tropical dysentery, or amebic dysentery. As in the forms already considered, the colon and rectum are the usual seats of the trouble, and, as in the former, are characterized by hyperemia and infiltration of the mucosa and submucosa, with the subsequent stage of ulceration. The ameba are found in the ulcers, in the coats of the bowels, and in the discharges. The infection is carried to the liver, probably through the portal circulation, and single or multiple abscesses are not infrequent. Abscess of the lung is a more infrequent result.

Chronic Dysentery.—In chronic dysentery the mucous membrane presents varied discolorations. Sometimes it is a dingy or brownish red, at other times of an ashy gray, or of a purplish-dusky hue. It is thickened in some parts, while denuded at others, thus giving portions of the gut a dilated or sacculated appearance, with stricture intervening. Ulcers of various sizes and shapes are found, while the entire bowel is bathed in a bloody or purulent mucus.

Symptoms.—Dysentery presents a variety of symptoms, depending upon the form of the disease and the amount of the bowel involved; also whether sporadic or epidemic. There is one group of symptoms, however, that is common to every form and may be said to be characteristic; viz., pain, tenesmus, and frequent, small, bloody, mucous stools.

Acute catarrhal dysentery, the form most frequently found in temperate climates, is very properly divided into sporadic and epidemic. The sporadic form, usually the milder, may be preceded for a few days by evidence of dyspepsia, with more or less uneasiness and pain in the abdomen.

Diarrhea is usually the earliest symptom, and may continue for twenty-four or forty-eight hours before the true dysenteric discharges are present. These begin by a frequent desire to go to stool, attended by colicky pain and tenesmus. The stools now are small, contain but little feculent matter, and consist of a jelly-like mass of mucus, with an admixture of more or less blood. There is a sensation as though the rectum is loaded, and must be emptied. There is great pain preceding and following each stool, with a peculiar burning sensation in the rectum.

There is some fever, though generally not of a very active character. The tongue is furred, and great thirst Is experienced, the gratification of which increases the irritation already existing, and aggravates the patient's suffering. Unless early overcome, the disease grows severer each day, the face takes on an anxious and pinched expression, and the disease assumes the character of the epidemic form.

The latter is usually the more severe in character, and is truly a grave disease. "Epidemic dysentery occurs in two principal forms, though there are various gradations: there are cases with obstinate constipation of the small intestines, with an active grade of fever; and others where there is an irritability of the intestinal tract, with a low or asthenic fever.

"In the first form, the disease almost always commences with a well-marked rigor or chill, followed by high febrile action. The discharges from the bowels soon become frequent, are preceded and attended by tormina, the pains being of a severe, cutting character. The tenesmus, or desire to evacuate the bowels, is almost constant, and is very distressing during the operation, it seeming to the patient that the desire for an evacuation would never cease.

"No rest can be obtained during this condition, and, a natural consequence, the patient is very fretful and uneasy. The discharges from the bowels are sometimes pure mucus, at others mucus mixed with blood, and again seemingly almost pure blood; in each case the material being unchanged, not dirty or discolored, as in the next form of the disease.

"As it continues, we find that day by day the disease becomes more severe. The fever is remittent or continued, and very active, the skin being dry and parched, the pulse hard and frequent, pain in the head and back, the tongue coated, a bad taste in the mouth, and loss of appetite, the urine scanty, sometimes passed with difficulty, and anxiety and uneasiness from the almost total loss of sleep from the commencement of the disease. Up to the sixth or seventh day the symptoms will be thus acute; but after that, we find the fever assuming a typhoid type, and the discharges from the bowels become discolored and offensive, as in the next variety.

"The second form frequently commences as above described, the fever following the chill, or rigor, being acute. The discharges from the bowels are small, and composed of mucus and blood, and attended with an intense tormina and tenesmus. But in the progress of the disease it is found that any cathartic will start the small intestines into action, and we have more or less offensive feculent matter passed with the dysenteric discharges, or alternately with them. When this occurs, the typhoid symptoms, described below, soon make their appearance.

"In other cases, the discharges are semi-diarrheal at the commencement, and we find this irritability of the small intestines, and sometimes of the stomach, continuing' throughout the progress of the disease. This feature of the disease must be noticed; for if we should give in this case a cathartic to increase secretion from the liver, and open the small intestines, we would many times set up an irritation that we would find it impossible to quiet."

Typhoid Dysentery.—Occasionally there is evidence of sepsis from the beginning of the attack. There is more or less depression from the start; patient feels tired, languid, and the bowels are loose. The tongue is broad, coated with a dirty, moist coating. The skin is clammy and relaxed; pulse small and quick; the temperature not very high, 100° or 101°, possibly 102°, and very rarely reaches 103°. As the disease progresses, the tongue becomes dry and brown, sordes appear on the teeth, while the stools become small and frequent, and are composed of mucus, blood, pus, and shreds of mucous membrane.

The stools vary in color. At times a grayish, pultaceous mucus; hence it is sometimes called gray flux. Again the mucus is pink or of-a purplish hue. Day by day the patient grows worse. The face takes on a pinched or haggard expression, the nose is thin and blue, the eyes sunken, the pulse small and feeble, the temperature drops, the extremities are kept warm with difficulty, a cold sweat covers the body, and the patient dies in a state of collapse.

The pain is not so intense in this form, the nervous system being benumbed by the sepsis. Complications with the liver are more apt to be seen in this form.

In all severe forms of dysentery, whether sporadic or epidemic, the tormina may extend to the bladder, causing intense suffering.

Complications.—A peritonitis may follow by extension of the inflammatory process, or in rarer and usually fatal cases, by perforation. Abscess of the liver has already been noted, and is not infrequent in hot climates. Pericarditis and endocarditis in rare cases follow dysentery, where the latter has been prolonged for weeks or months. Paralysis has been noted in but few cases.

Diagnosis.—Dysentery is one of the most readily recognized of diseases of like severity. The frequent call to stool, the great tormina and tenesmus, the character of the stools, jelly-like mucus mixed with blood, or the stool may be entirely of blood, the intense thirst and systemic disturbance can not be mistaken for any other condition. The inexperienced might possibly mistake a proctitis or hemorrhoids, fissure, stricture, or sympathetic irritation from the bladder for dysentery; but if one remembers the far greater systemic disturbance of dysentery, the mistake will be avoided.

Prognosis.—Although a grave disease, especially in the epidemic and typhoid forms, the Eclectic treatment has been peculiarly successful. In exceptional epidemics, where the type is peculiarly malignant, the prognosis must be guarded.

Treatment.—The treatment of dysentery consists not only in the proper selections of remedies, but in good nursing and careful attention to diet, for a great deal depends upon the care the patient receives. The patient should be put to bed with the first dysenteric stool, and perfect quiet enjoined. He must be impressed with the necessity of resisting the call to stool as far as possible; for many times the desire will pass away if the patient only exerts a little will power. Drinking waiter should be restricted, though bits of cracked ice may be allowed.

The diet should consist of hot milk, given in small quantities; if cow's milk can not be taken, malted milk in some form should be given. Albumen-water in very small quantities is well received; also scraped beef; but if irritation follows, it should at once be withheld. During convalescence cooked fruits may be used to advantage. Unless the patient has been constipated, and there is accumulation of feces, cathartics should not be given.

In sporadic dysentery the treatment, is simple.

Sig. Teaspoonful every hour will be sufficient to effect a cure.

The aconite quiets the fever, and the ipecac relieves the intestinal irritation.

Where there is marked tenderness over the abdomen, dioscorea may be either alternated with the above, or replace the ipecac.

For the tenderness, and especially for the burning sensation in the rectum, tincture colocynth will be found a valuable remedy. Where there is nausea, the tongue pale, a white ring around the mouth, pain pointing to the umbilicus, tincture nux vomica, 5 drops, to water 4 ounces, will give prompt relief.

If the tongue be moist and red, with an irritable stomach, subnitrate bismuth in mint-water should be used, a teaspoonful every one, two, or three hours.

Where the tongue is red and elongated,

Sig. Teaspoonful every hour will give quick results.

The remedy, however, which will fit more cases than any other is the "white liquid physic." My father used the old formula, with the alum left out, and was remarkably successful in his treatment of dysentery. His prescription was :

Where the patient was very thirsty, as he usually was, the doctor would put a teaspoonful in a fourth of a glass of water, and let the patient sip at pleasure; this quenches the thirst, and does not start the bowels. Of this treatment Dr. Cooper says, "White liquid physic comes as near being a specific for a given disease as any remedy can be."

Some patients can not take the remedy as strong as the above, and therefore it must be diluted. Thus I was called to see a very grave case of dysentery, where the stomach rejected all medication. On suggesting white liquid physic, the attending physician informed me that he had given the remedy, but the patient could not retain it. I then added one teaspoonful of the agent to a half glass of water, and the remedy was not only retained, but improvement began at once, and continued to recovery.

Where the call to stool is almost constant, and attended by great pain, an enema of starch and laudanum will afford relief; ten to thirty drops of laudanum to a tablespoonful of starch-water, the injection to be retained as long as possible. My friend, Dr. Eben Behymer, prefers the use of the opium suppository for the same condition; or, if the rectum is very irritable, a half grain of powdered opium, in a small No. 4 capsule, will be better retained than a suppository.

Where the pain is unbearable, a hypodermic of morphia is justifiable, or a hot sitz-bath may answer the same purpose.

Where malaria prevails and there is a distinct periodicity manifested, quinia will be necessary in effecting a cure.

In epidemic dysentery, the treatment just outlined may be sufficient, though special cases will need careful study and additional treatment. In some epidemics the conditions are so similar, that nearly all cases will be benefited by the same medication, or, in other words, epidemic remedies meet the diseased condition, and the treatment is very simple. For example, the epidemic that prevailed so extensively at Harrison, Ohio, in 1868, and in which many died, was one in which the second trituration of Podophyllin was a specific. My father was going night and day for several weeks, yet only lost two cases, and those elderly patients. Here the tongue showed the yellowy pasty coating, the yellow skin, full veins, and full tissue.

here the evidence of sepsis is marked, showing typhoid symptoms, each case needs special study. The dirty, moist, pasty coating on the tongue calls for sodium sulphite. The slick, moist, red tongue, or spoiled-beef tongue, calls for sulphurous acid, while the dry, brown tongue, with sordes on the teeth, calls for hydrochloric acid. Echinacea and baptisia will be the remedies where the tissues are full and present a purplish or frozen appearance and the stools are of a prune-juice character, with shreds of mucus.

Where the bowel is not too sensitive, washing out the gut with boracic acid solution is good treatment. Where there is but little fever and the tissues are relaxed, nothing is better than sub-gallate of bismuth and opium. Five to ten grains of the former, and one-fourth grain of the latter, every three or four hours.

Where the tongue presents a yellowish or bluish color, with a dirty, moist coating, with a bad breath somewhat cadaveric, potassium chlorate and hydrastin phosphate should be administered.

It is hardly necessary to say, in this day of antiseptics, that the patient should be kept clean, and that his room should be well ventilated, and that Pratt's chlorides, or some equally good disinfectant, should be used freely.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.