Dysentery

Dysentery (from the Gr. prefix δυσ-, in the sense of “bad,” and ἔντερον, the intestine), also called “bloody flux,” an infectious disease with a local lesion in the form of inflammation and ulceration of the lower portion of the bowels. Although at one time a common disease in Great Britain, dysentery is now very rarely met with there, and is for the most part confined to warm countries, where it is the cause of a large amount of mortality. (For the pathology see Digestive Organs.)

Recently considerable advance has been made in our knowledge of dysentery, and it appears that there are two distinct types of the disease: (1) amoebic dysentery, which is due to the presence of the amoeba histolytica (of Schaudinn) in the intestine; (2) bacillary dysentery, which has as causative agent two separate bacteria, (a) that discovered by Shiga in Japan, (b) that discovered by Flexner in the Philippine Islands. With regard to the bacillary type, at first both organisms were considered to be identical, and the name bacillus dysenteriae was given to them; but later it was shown that these bacilli are different, both in regard to their cultural characteristics and also in that one (Shiga) gives out a soluble toxin, whilst the other has so far resisted all efforts to discover it. Further, the serum of a patient affected with one of the types has a marked agglutinative power on the variety with which he is infected and not on the other.

Clinically, dysentery manifests itself with varying degrees of intensity, and it is often impossible without microscopical examination to determine between the amoebic and bacillary forms. In well-marked cases the following are the chief symptoms. The attack is commonly preceded by certain premonitory indications in the form of general illness, loss of appetite, and some amount of diarrhoea, which gradually increases in severity, and is accompanied with griping pains in the abdomen (tormina). The discharges from the bowels succeed each other with great frequency, and the painful feeling of pressure downwards (tenesmus) becomes so intense that the patient is constantly desiring to defecate. The matters passed from the bowels, which at first resemble those of ordinary diarrhoea, soon change their character, becoming scanty, mucous or slimy, and subsequently mixed with, or consisting wholly of, blood, along with shreds of exudation thrown off from the mucous membrane of the intestine. The evacuations possess a peculiarly offensive odour characteristic of the disease. Although the constitutional disturbance is at first comparatively slight, it increases with the advance of the disease, and febrile symptoms come on attended with urgent thirst and scanty and painful flow of urine. Along with this the nervous depression is very marked, and the state of prostration to which the patient is reduced can scarcely be exceeded. Should no improvement occur death may take place in from one to three weeks, either from repeated losses of blood, or from gradual exhaustion consequent on the continuance of the symptoms, in which case the discharges from the bowels become more offensive and are passed involuntarily.

When, on the other hand, the disease is checked, the signs of improvement are shown in the cessation of the pain, in the evacuations being less frequent and more natural, and in relief from the state of extreme depression. Convalescence is, however, generally slow, and recovery may be imperfect—the disease continuing in a chronic form, which may exist for a variable length of time, giving rise to much suffering, and not unfrequently leading to an ultimately fatal result.

The dysentery poison appears to exert its effects upon the glandular structures of the large intestine, particularly in its lower part. In the milder forms of the disease there is simply a congested or inflamed condition of the mucous membrane, with perhaps some inflammatory exudation on its surface, which is passed off by the discharges from the bowels. But in the more severe forms ulceration of the mucous membrane takes place. Commencing in and around the solitary glands of the large intestine in the form of exudations, these ulcers, small at first, enlarge and run into each other, till a large portion of the bowel may be implicated in the ulcerative process. Should the disease be arrested these ulcers may heal entirely, but occasionally they remain, causing more or less disorganization of the coats of the intestines, as is often found in chronic dysentery. Sometimes, though rarely, the ulcers perforate the intestines, causing rapidly fatal inflammation of the peritoneum, or they may erode a blood vessel and produce violent haemorrhage. Even where they undergo healing they may cause such a stricture of the calibre of the intestinal canal as to give rise to the symptoms of obstruction which ultimately prove fatal. One of the severest complications of the disease is abscess of the liver, usually said to be solitary, and known as tropical abscess of the liver, but probably is more frequently multiple than is usually thought.

Treatment.—Where the disease is endemic or is prevailing epidemically, it is of great importance to use all preventive measures, and for this purpose the avoidance of all causes likely to precipitate an attack is to be enjoined. Exposure to cold after heat, the use of unripe fruit, and intemperance in eating and drinking should be forbidden; and the utmost care taken as to the quality of the food and drinking water. In houses or hospitals where cases of the disease are under treatment, disinfectants should be freely employed, and the evacuations of the patients removed as speedily as possible, having previously been sterilized in much the same manner as is employed in typhoid fever. In the milder varieties of this complaint, such as those occurring sporadically, and where the symptoms are probably due to matters in the bowels setting up the dysenteric irritation, the employment of diaphoretic medicines is to be recommended, and the administration of such a laxative as castor oil, to which a small quantity of laudanum has been added, will often, by removing the source of the mischief, arrest the attack; but a method of treatment more to be recommended is the use of salines in large doses, such as one drachm of sodium sulphate from four to eight times a day. This treatment may with advantage be combined with the internal administration of ipecacuanha, which still retains its reputation in this disease. Latterly, free irrigation of the bowel with astringents, such as silver nitrate, tannalbin, &c., has been attended with success in those cases which have been able to tolerate the injections. In many instances they cannot be used owing to the extreme degree of irritability of the bowel. The operation of appendicostomy, or bringing the appendix to the surface and using it as the site for the introduction of the irrigating fluid, has been attended with considerable success.

In those cases due to Shiga’s bacillus the ideal treatment has been put at our disposal by the preparation of a specific antitoxin; this has been given a trial in several grave epidemics of late, and may be said to be the most satisfactory treatment and offer the greatest hope of recovery. It is also of great use as a prophylactic.

The preparations of morphia are of great value in the symptomatic treatment of the disease. They may be applied externally as fomentations, for the relief of tormina; by rectal injection for the relief of the tenesmus and irritability of the bowel; hypodermically in advanced cases, for the relief of the general distress. In amoebic dysentery, warm injections of quinine per rectum have proved very efficacious, are usually well tolerated, and are not attended with any ill effects. The diet should be restricted, consisting chiefly of soups and farinaceous foods; more especially is this of importance in the chronic form. For the thirst ice may be given by the mouth. Even in the chronic forms, confinement to bed and restriction of diet are the most important elements of the treatment. Removal from the hot climate and unhygienic surroundings must naturally be attended to.

Bibliography.—Allbutt and Rolleston, System of Medicine, vol. ii. part ii. (1907), “Dysentery,” Drs Andrew Davidson and Simon Flexner; Davidson, Hygiene and Diseases of Warm Climates (Edinburgh, 1903); Fearnside in Ind. Med. Gaz. (July 1905); Ford in Journal of Tropical Medicine (July 15, 1904); Korentchewsky in Bulletin de l’Institut Pasteur (February 1905); Shiga: Osier and M’Crae’s System of Medicine, vol. ii. p. 781 (1907); Skschivan and Stefansky in Berliner klinische Wochenschrift (February 11, 1907); Vaillard and Dopter, on the treatment by antidysenteric serum, Annales de l’Institut Pasteur, No. 5, p. 326 (1906); J.A. Pottinger, “Appendicostomy in Chronic Dysentery,” Lancet (December 28, 1907); Robert Doerr, Das Dysenterietoxin (Gustav Fischer, Jena, 1907); F.M. Sandwith, “Hunterian Lecture on the Treatment of Dysentery,” Lancet (December 7, 1907).

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