GEN. X. SPEC. I. B D. acuta pyrectica. Pyrectic complicated of all mate rials. the disease. the dissimilarity of the disease in this respect in these distinct quarters*. The patient on going to stool, whatever be the disdysentery. charge that ensues, has always a feeling of something remaining in the bowels which ought to be dejected; Dejections while the dejections themselves, according to the extent and violence of the inflammatory action and its effects, evince every combination of materials: being, in consistency, watery, like beef-washings, slimy, mucous, purulent, bloody; in hue, drab-coloured, like flummery, bright-green like conferva, and, after opium and calomel, deep-green; sometimes pitchy †, and extremely fetid; and sometimes loaded with shreds of detached membranes; Progress of while occasionally a feculent motion is thrown down, of a natural colour, and nearly of a natural spissitude. Meanwhile, to adopt the description of Sydenham, the strength is much exhausted, the animal spirits dejected; there are all the signs of an ill-conditioned fever; intolerable sickness and excruciating pains, and a deadly coldness of the extremities. Insomuch that the disease in many instances, and especially when unskilfully treated, endangers the patient's life much earlier than in most other acute diseases. But if the patient should escape death in this way, still numerous symptoms of a different Sometimes kind succeed. Sometimes in the progress of the disease, pure blood discharged. instead of the membranous shreds which are usually mixed with the stools at the commencement, pure blood, unmixed with mucus, is profusely discharged at every evacuation, which of itself threatens death, as manifesting an erosion of some of the larger vessels of the intesSometimes tines. Sometimes a fatal gangrene seizes the intestines gangrene in consequence of the inflammation being aggravated by an afflux of hot acrid matter to the affected parts. Towards the close of the disease aphthæ frequently affect the interior of the mouth, and generally foreshow imminent death. Aphthæ. * Dublin Reports, &c. ut suprà, p. 20. + O'Brien on Acute and Chronic Dysentery, p. 58. GEN. X. SPEC. I. These symptoms are confirmed by practitioners in every climate. Dr. Chisholm, alluding to the aphthæ & D. acuta that so frequently precede the final stage, observes, very pyrectica. Pyrectic justly, that they are produced by an extension of the in- dysentery. flammation from the intestines to the stomach, and even Aphthæ acthe fauces; during which, instead of an increased secre- by Chisholm. tion of mucus, there is an increased "exudation of lymph which assumes the appearance of little granulated masses, under and around which inflammation discovers itself with a bright florid colour."* The rapidity with which acute dysentery, when connected with fever, rushes on to destruction, more so indeed than in most other acute diseases, is particularly noticed by Dr. Cheyne, who ascribes the fatal issue in this case to the violence of the fever itself rather than to the proper dysenteric symptoms: though he adds, that sometimes sudden death ensued from an escape of the contents of the intestines into the cavity of the peritonæum, in consequence of ulceration +. counted for Fatal issue often rapid. The afflux of hot acrid matter alluded to by Syden- Afflux of hot ham is not unfrequently derived from the liver, and acrid matter. indicates a very morbid condition of this organ; and to the same effect Dr. Johnson;-" We sometimes see a partial ill-conditioned sweat on the surface, which is productive of no benefit: while from the liver an occasional gush of vitiated bile, like so much boiling lead, throws the irritable intestines into painful contortions, and then the tormina and tenesmus are intolerable." There is occasionally, at this time, a formation of black Sometimes vomit, the stomach discharging frequently a dark fluid, with a precipitate like coffee-grounds §. black vomit. signs indica Dr. Chisholm observes that the signs which chiefly Whether show us that the disease has extended to the liver are, tive of an a "pain at the pit of the stomach, and a head-ache, a considerable anxiety at the præcordia, and a sensation • Climate and Diseases of Tropical Countries, p. 62. + Vide suprà, p. 20. Influence of Tropical Climates, ut suprà, p. 194. § Dublin Hospital Reports. Vol. ш. p. 32. affection of the liver. GEN. X. SPEC. I. B D. acuta pyrectica. Pyrectic dysentery. as of a continued pressure in the right hypochondrium, with frequent stools, composed of a fluid like the washings of raw meat."* But he admits, as we have already noticed, that these are not idiopathic, and consequently are not to be depended upon for this purpose. They prove, however, that the disease has made an extensive inroad upon the constitution. Yet there are not unfrequently signs that it has extended still further, and that Sometimes the lungs themselves are affected, not merely in their the lungs function, but in their structure: for the respiration, obaffected. serves Dr. Cheyne, was sometimes suddenly suppressed in the advanced stages; there was pain in the chest, a teasing dry cough, showing a translation of the disease to the lungs; an exudation of puriform mucus in the cavity of the bronchia, being detected on dissection f. Fatal prognostics. Mortality often dreadful. “A harsh, dry, opake, dirty-looking skin; a florid, clear, varnished tongue; vigilance; a hollow eye, and pallid, wasted, faded cheek; pains in the knees; cramp in the legs; fits of dyspnoea; tendency to edema and ascites-belonged to the more advanced stage, but not to the last; which was characterised by extreme emaciation, supine posture, involuntary stools, a thin reddish secretion, flowing without check; sordes on the teeth; hiccough; tendency to delirium; difficulty of swallowing; thread-like pulse."+ The mortality is often dreadful. At Clonmell, in 1818, where however it was far less severe than in many other parts of Ireland, Mr. Dillon calculated the deaths at one in ten; at Cork, during the same year, Dr. Barry estimated it at one in three at the least. "I never," says he, "witnessed so fatal a disease." And to the same effect, in general terms, Dr. Cheyne, while practising at Dublin: "I had often witnessed obstinate cases of dysentery, but I had not formed an adequate conception of the horrors of that disease, until I saw the patients who were congregated in the wards of Whitworth Hospital." * Ubi suprà, p. 59. + Suprà, p. 25. Suprà, p. 23. SPEC. I. 6 D. acuta Pyrectie examina POST-OBIT EXAMINATIONS were made in the dissecting GEN. X. room of this hospital upon a very extensive scale, and gave evident proof, first, that the primary and CHIEF pyrectica. SEAT OF THE DISEASE WAS THE INTESTINES; though dysentery. the liver often participated in the general lesion; and, Post-obit secondly, that the intestinal canal was very variously tions. diseased, according to the length or severity of the attack, or the peculiarity of the patient's constitution. In some cases the canal was prodigiously distended; Affected in in others the coats were greatly injured, but without any thickening; in others again they were considerably thickened, as well as otherwise diseased. Where distention prevailed, the small intestines were, in a few instances, found to be not less than seven, and the large not less than nine, inches in circumference. Where the intestinal coats were without incrassation the inflammation of the mucous membrane was sometimes still very extensive, and reached from the stomach. to the rectum; being however more obvious as the larger intestines were approached; though occasionally this last intestine was still pretty sound for three or four inches above the sphincter. The mucous membrane was sometimes increased in vascularity without abrasion, or ulceration; sometimes covered with coagulable lymph; sometimes simply abraded of its epidermal coat; sometimes partly ulcerated, and irregularly exposing the muscular coat; the intervening portions being of a natural appearance. Chief seat of disease in the intestines. various ways. and severe when the Where the intestinal coats were thickened, the mis- Disease long chief seems to have been generally more severe; the internal surfaces were often rugous as well as ulcerated, coats are exposing the muscular fibres more extensively, which thickened. often hung in shreds as if sphacelated. The process of thickening, moreover, belonged to the more protracted cases, and often measured the duration of the disease*. This incrassation is traced chiefly in the colon, which Dr. Chisholm has found sometimes a quarter of an inch * Medical Report, &c. pp. 28, 34. This effect chiefly in the colon. GEN. X. SPEC. I. B D. acuta pyrectica. Pyrectic thick and full of minute abscesses, and small steatomatous excrescences*. These last appearances are particularly noticed by Dr. Cheyne, but described differentdysentery. ly; "they are not", says he, "small ulcers, but minute pin-holes formed out of the enlarged ducts of mucous glands; they were found very numerously, but especially in the rectum, and lower part of the colon." By Dr. Baillie they are described as excrescences resembling warts †. Liver com but often otherwise. "The LIVER", says Cheyne, "IN A MAJORITY OF monly sound CASES WAS SOUND, but often otherwise. In two cases there were abscesses; and in many great sanguineous congestion." To a like effect Dr. O'Brien, writing from the same capital at a later period: "Generally”, says he, "the liver was unaffected; though the gallbladder was always distended with deep-brown, or dark yellow bile." Both these appearances were particularly observed by Dr. Chisholm in the West Indies, thus again harmonizing the nature of the disease in climates of different temperatures. "Where the colon was thus diseased it was prodigiously distended with air. All the rest of the intestinal canal was healthy, the liver was equally so, but the gall-bladder was of a most uncommon size and full of yellow bile." The same undeviating show of mischief in the intestinal canal, with only an occasional appearance of morbid structure in the liver occurred to Dr. Ballingall in India, and to Dr. L. Frank in Egypt: so that the real source of the disease can be no longer a matter of doubt. "The dissection of every subject", says the former, "who died of dysentery in the regimental hospital of Penang (with one solitary exception), proved the disease to consist entirely in an inflammatory affection of the large intestines, without a trace of disease in the structure of the liver."¶ • Climate and Diseases of Tropical Countries, p. 56. Practical Observations on Fever, Dysentery, and Liver Complaints, &c. |