tinal symptoms. In protracted cases rectal examination should always be
made in order to exclude malignant tumor.
Tropical Dysentery.
Synonyms. Epidemic Dysentery; Bacillary Dysentery.
Definition. A specific inflammation affecting the colon and sometimes
the small intestine and characterized by the exudation of a false membrane
which may be cast off, leaving ulcerative surfaces behind.
.etiology. This affection is a common disease of tropical and temperate
cHmates and especially prone to appear where large numbers of persons are
gathered under unsanitary surroimdings as in army camps, ships and hos-
pitals. It often appears in epidemics. Its specific cause is the bacillus
dysenteruB discovered by Shiga dtiring an epidemic in Japan. Other observers
have confirmed his observations in the Philippine Islands and in other coun-
tries. This micro-organism is not found in the normal intestine but may
persist in this situation after an attack of the disease which may account
for the dissemination of the infection in regions where it has been prevalent.
It has appeared in the United States since the return of our soldiers from
China and from the West Indies. Its mode of transmission is by means of
drinking water or other contaminated ingesta.
Pathology. The changes observed depend upon the severity of the
infection. In mild forms the mucous lining of the intestine is inflamed,
swoUen and covered with a croupous exudate which is easily detachable and
is composed of necrotic epithelium. In the more severe grades this exudate
involves all the coats of the intestine and appears as a grayish or brownish
mass of granular surface which may cover the entire lining of the colon
or may affect localized areas only. Portions of this pseudo-membrane may
be sloughed away, ulcers, varying in extent, being left behind. A follicular
form of inflammation may occur without membrane formation in which the
intestinal lining is at first swollen and congested, the follicles, especially those
of the caecum, being inflamed and ulcerated. These ulcers may extend to the
muscular coat; their edges are ragged and overhanging. Cicatrization may
64 THE INFECTIOUS DISEASES.
take place, and ulcerations in all stages may be observed at the same time.
In other instances a gangrenous process may follow the diphtheritic inflam-
mation. Here the serous coat is affected and adhesions are common; the
wall of the gut is easily torn, is necrotic and dark olive green in color with here
and there areas which are quite black. Its hnmg is the seat of diffuse puru-
lent in^tration with localized areas of necrosis and gangrene. Portions
of the mucosa may not be involved in the above described t)'pes of inflam-
mation but are the seat of simple catarrhal changes.
Symptoms. The onset is usually sudden and may be characterized by
a chill. The temperature rises rapidly — 102° to 103° F. (39° to 39.5° C.) —
the prostration is marked and cerebral symptoms, even delirium, may be
present. The temperature is irregular with remissions from time to time,
the piflse is rapid and soon becomes feeble; irregularity of force and frequency
may be noted.
There is severe abdominal pain and the stools are frequent, small, dark ir
color, fcetid and contain caucus and blood. Pieces of pseudo-membrane may
be cast off, varying from a small shred to a tube cast of the gut of considerable
size. Tenesmus is Hkely to be a distressing symptom and the abdomen may
be distended and tender. In persistent cases the stools are likely to become
serous and more profuse. Such dejecta are markedly albuminous, and may
be reddish, due to the presence of blood. The patient becomes rapidly
weak and emaciated and suffers from thirst; the mouth is dn^ and the tongue
foul and coated. In severe infections delirium may be followed by coma.
Milder subacute types of the disease may occur in which the symptoms are
not marked and the stools as few as five or six per day.
The diagnosis may be made upon the rapid development of intestinal
and constitutional symptoms, and the appearance of bits of membrane in the
dejecta. It is assured by the isolation of Shiga's bacillus from the stools
and by obtaining a positive agglutination reaction with pure cultvires of this
bacillus when mixed with the blood-serum of the patient.
The prognosis in this type of dysentery is distinctly unfavorable, recover}^
may, however, occur or the disease may become clironic.
Complications such as localized peritonitis, intestinal rupture with subse-
quent general peritoneeal infection may be observed. Hepatic abscess is less
frequent than in amoebic dysenter}\ Pleurisy, pericarditis and endocar-
ditis are infrequent complications.
Amoebic Dysentery.
Definition. An inflammation of the large intestine characterized by
the formation of ulcers and due to the amceha coli.
.Etiology. This disease is most common in tropical countries but has
DYSENTERY. 65
also been observed in the southern United States and more infrequently in
those farther north. It mayocciir at any age but is most common diiring
the third decade of life and seems to affect males more frequently than females.
Its specific cause is the amceba coli which is found in the stools, the intestinal
ulcerations and in the pus from liver abscesses which commonly complicate the
disease. This organism is from 15 to 20 microns in diameter, spheroidal in
form and, when living, actively motile. It is composed of two portions, an
outer, the ectosarc, and an inner, the endoscarc. It moves by propelling the
former, after which the endosarc follows by flowing into the pseudopodia
thus extruded. The amoeba is phagocytic taking into its substance red blood
cells and other bodies occurring in the intestine. It- is said that the virulence
of this micro-organism is much enhanced by the presence of other pathogenic
bacteria.
Its mode of transmission is usually by means of drinking water or vtpon
other ingesta contaminated with infective water and consequently the disease,
of which it is the cause, may be in great measure prevented by proper attention
to water supply and by thorough disinfection of the discharges of affected
individuals.
Pathology. The intestinal changes are confined almost wholly to the
large intestine and are but seldom found in the ileum. The ulceration
involves first the submucosa of the gut but spreads thence to the mucosa. The
muscularis is rarely and the peritonaeal coat stiU more seldom, afi'ected. The
first changes noted are a number of areas of congestion in the submucous
coat; these are followed by necrosis of this and a sloughing process which
involves the mucous coat as well and leaves behind ulcers of varying size
and depth. The peritonasal coat rarely shares in the inflammation and
perforation is a rare occurrence. Pus is present in surprisingly small
amount considering the extent and type of the process and extensive
necrosis of the submucosa may be observed with no or only slight involve-
ment of the mucosa, the inflammation dissecting its way downward and
laterally rather than toward the lumen of the intestine. The ulcers may
be circiflar or ovoid, with ragged floors and overhanging edges and may
involve nearly the whole of the colonic lining including that of the appendix.
In them the amoebae are present; these may also be foimd in the lymph
spaces and more rarely in the neighboring blood-vessels.
As the ulcers heal their bases become covered with fibrous tissue which
may later contract and cause strictures or even sacs in which the amoebafc
may remain after the patient seems to have recovered. Thickenings and
adhesions of the colonic wall may be observed.
The hepatic lesions are probably the result of the entrance of the parasites
into the portal capillaries and are of two types: First, multiple circum-
scribed areas of necrosis, and second, abscesses, single or multiple. The
5
66 THE INFECTIOUS DISEASES.
former lesions are thought to be due to the action of the products of the
growth of the parasite, the latter, if recent, contain within their cavities, which
are large if single, small if multiple, necrotic matter of semifluid consistency
and reddish — or greenish — ^yellow color. On close inspection this is seen to
be composed of a spongy net-work of tissue in the interstices of which a viscid
fluid isi confined. The walls of the recent abscesses are ragged and necrotic
while those of long standing are lined by firm, dense fibrous tissue. Micro-
scopic examination of the contents of the abscess reveals the presence of
necrotic liver ceUs and amoebae. True pus is not present unless mixed infec-
tion has taken place. Such pyogenic bacteria as staphylococci, streptococci,
colon bacilli, etc., have been found.
Large single abscesses are usually near the upper or lower surfaces of the
right lobe while the smaU multiple abscesses are scattered through the organ
and may be at no great distance from its surface.
Hepatic abscesses may rupture, depending upon their site, into any of the
surrounding organs or through the abdominal wall. They may perforate
the diaphragm and biu-st into the lung, whence their contents may be coughed
up.
Associated lesions which may be observed are nephritis and cerebral conges-
tion with or without capillary haemorrhages.
Symptoms. In cases of acute onset the symptoms are practically those
of dysentery due to the baciUus of Shiga (see p. 64). The temperature is
seldom high but the patient is greatly prostrated and becomes rapidly and
to a marked degree emaciated. Intestinal haemorrhage or perforation may
occur. While recovery usuaUy takes place in two or three months, in severe
grades of the infection death may take place within a week or ten days or,
the disease becoming chronic, the patient continues to suffer from alternating
diarrhoea and constipation, exacerbations occmrring from time to time during
which the pain and temperatiu^e recur and diarrhoea with the passage of
mucus and blood makes its appearance. Between the exacerbations the patient
enjoys periods of improvement but a recurrence of the symptoms may be
brought about by errors in diet or exposure; while often enough the patient's
nutrition remains good, in other instances emaciation may be marked.
In another chronic type of the disease the ulceration persists and with it
the diarrhoea; the emaciation is progressive and death from exhaustion super-
venes within a few months.
The complication to be particularly anticipated is liver abscess, the presence
of which is evidenced by an increase in the area of liver dulness, pain, leuco-
cytosis and a temperature of septic type accompanied by chills and sweating.
Other possible complications are peritonitis, intestinal haemorrhage or per-
foration, pylephlebitis, pleurisy, pericarditis, endocarditis and arthritis.
Malaria and typhoid fever have been observed in co-existence with this disease.
DYSENTERY. 67
The diagnosis of this affection is to be based upon the finding of the amoebae
in the patient's dejecta. They should be searched for upon a warmed stage
and a positive diagnosis should not be made unless amoeboid movement
is observed.
The prognosis of amoebic dysentery in epidemics and without proper treat-
ment is unfavorable; in sporadic cases the mortality is low. Recurrences
are prone to occur and in the patients in whom the disease is complicated
by hepatic abscess the chances of recovery are greatly diminished.
Diphtheritic Dysentery.
This form of dysentery occurs secondary to the acute infectious diseases*
pneumonia, enteric fever, etc., and to certain chronic affections such as endo-
carditis, nephritis and pulmonary tuberculosis.
Pathology. While termed diphtheritic this condition is not a result of
Klebs-Loffler infection. It is characterized by the appearance of a pseudo-
membranous exudate of yellowish or grayish color upon the mucous lining
of the intestine and by necrotic ulcerative areas. The supporting connective
tissue of the colonic glands is inflamed and infiltrated with fibrin and pus
ceUs. The process may involve the muscular and peritonaeal coats as weU.
The inflammation may be confined to the rectum or the whole colon may be
involved, its entire surface being covered with the exudate or merely scattered
areas of pseudo-membrane being present. In markedly severe instances the
necrotic patches may slough leaving ulcers behind which either cicatrize or
remain active for long periods.
Symptoms. The onset of this disease is gradual being characterized
by the appearance of slight or moderate diarrhoea, the stools being fluid, not
often accompanied by pain or tenesmus and seldom more than from three
to five daily. In mild cases the passage of mucus and blood rarely is observed
but in the severer types of the disease these with shreds of membrane may
appear in the dejecta. The affection is usually subacute or chronic in its
course and is associated with emaciation. Death may take place from asthe-
nia.
The Treatment of Dysentery.
Under this caption the means applicable to the treatment of all types of
the affection will be first discussed, to be followed by a description of those
especially indicated in the different forms of the disease.
General Considerations. In all forms of dysentery the prophylaxis consists
in boiling all possibly contaminated drinking water, disinfecting and des-
troying the patient's dejecta and in taking all the other precautions laid down
in the section upon the prevention of enteric fever (p. 9). Much work
68 THE INFECTIOUS DISEASES.
has been carried on recently along the lines of preventive inociilation against
bacillary dysentery and it is quite probable that we may in the not far distant
future have at our disposal an effective immunizing serum against Shiga
bacillus infection.
At thf onset of any of the varieties of dysentery the patient should be imme-
diately put to bed and if the catarrhal type is the one in hand a pm"ge of
castor oil, one ounce (30.0) with 20 grains (1.33) of sodium bicarbonate should
be given.
The pains and tenesmus may be controlled by the application of turpentine
stupes or mild sinapisms to the abdomen and by the administration of Dover's
powder by mouth. In instances where these means fail morphine may be
given hypodermatically.
The feeding of the patient offers difl&culties, for we have a distiurbed diges-
tive tract and one which must be irritated as little as possible, and at the same
time we have to combat a disease, one of the most prominent characteristics
of which is loss of strength and emaciation. Milk has its disadvantages since
the curds which are formed in the stomach may be impossible of digestion by
an alimentary tract the powers of which are impaired; the curds also are
excellent culture media for the growth of the micro-organisms which are
present in the intestine. Curd formation may be prevented by taking the
milk in small amounts and diluted with lime water or vichy or barley water,
or in the form of kumyss or zoolak. Peptonized milk may also be tried, soups
and broths may be permitted. When milk is not well borne easily digestible
semi-soHds, which may be partly predigested by means of pancreatin or
diastase, such as soft boiled eggs, meat jellies, milk toast, junket, etc., are
allowable.
The diet in the protracted forms of diphtheritic or amoebic dysentery may
be more liberal. While milk plays an important part here such nourishing and
easily digestible solids as raw oysters, cereals, poultry and fish may be given
in small quantities and tentatively. As the patient recovers a still more
liberal dietary may be gradually permitted.
Various forms of drug treatment may be employed in catarrhal and bacillary
dysentery; the so-called saline treatment is indicated particularly in sthenic
cases with high fever and in many instances achieves excellent results. Instead
of the initial dose of castor oil, a purgative dose of magnesium sulphate or
sodium and potassium tartrate is given and the intestine thoroughly evacu-
ated. Then, upon the theory that intestinal micro-organisms cannot exist
or at least are inhibited in their growth by an acid medium, aromatic sul-
phuric acid is given in 20 drop (1.33) doses three times a day. By this
means, not only are the intestinal bacteria retarded in their development,
but the astringent action of the acid is also exerted.
The ipecac treatment may be employed in all forms of dysentery and is
DYSENTERY. 69
to be carried out as follows: The drug is administered upon the empty
stomach and it may be wise to apply mild coxmterirritation over the stomach
in the form of a mild mustard paste or by painting with iodine before giving
the ipecac. The amount of this drug which is administered is large and
under ordinary circumstances would produce emesis, consequently the patient
should not be told of what the medication consists and he should be warned
not to vomit if he can avoid it. The size of the dose is in proportion to the
severity of the disease and weakness is not a contraindication. Preceding
the administration of the ipecac a dose of 10 to 15 drops (0.66 to i.o) of tinc-
ture of opium is given and after a quarter of an hour from 15 to 60 grains
(1.0 to 4.0) of ipecac, depending upon the age of the patient and the type of
the infection, are taken. The drug may be given in pill form or suspended
in a little water to which a little peppermint or anise oil has been added. Should
emesis be induced the dose should be repeated as soon as the stomach is
at rest. The ipecac may be given for considerable periods, the dosage being
diminished as the dysentery becomes less marked in severity.
Intestinal antiseptics may be employed as advised in the treatment of chronic
diarrhoeal conditions (see p. 384), but are usually less effective than the
forms of treatment described above.
Treatment by means of intestinal irrigations often brings about good results.
The apparatus necessary consists of a fountain syringe to which a long rectal
tube of soft rubber is attached. When the intestine is very irritable it may be
wise to pass a soft catheter beside the tube to carry off the return flow and
prevent distention of the bowel. Forcible irrigation is contraindicated, a
gentle flow, the receptacle containing the fluid to be used being held at a
height not greater than three or four feet above the patient, being preferable.
Careful introduction of the tube is necessary and a skilled hand may often
succeed in passing the same well beyond the sigmoid flexure. The discom-
fort accompanying its passage in instances of severe tenesmus may be obviated
by the insertion of a cocaine — gr. J to J (0.016 to 0.032) — and iodoform — gr.
viii (0.5) — suppository shortly before the procedure. The quantity of the irri-
gation selected may be from one to two gallons (4 to 8 litres), although irri-
gations so large in amount may at first be intolerable to the patient; we may
by beginning with small quantities gradually increase until the bowel becomes
tolerant and the patient's discomfort endurable. The insertion, previous
to the injection, of such a suppository as that given above or the injection
of a drachm (4.0) of tincture of opium in a little starch water will often
render the subsequent irrigation well borne. The temperature of the irri-
gation is an important consideration, cold irrigations being indicated in
sthenic cases while, when stimulation is desirable, higher temperatures are
advisable. Tepid irrigations are seldom employed.
Various solutions have been employed in the different types of dysentery.
7© . THE INFECTIOUS DISEASES.
In the simple catarrhal and the diphtheritic forms simple cold water, or hot
saline solution may be employed. Here also astringent solutions such as
alum (2, percent.), zinc phenolsulphonate (0.25 percent.), silver nitrate (0.25
percent.), tannic acid and salicylic acid (i to 2 percent.), silver-protein
(protargol) (0.75 percent.) are of use*. An infusion containing 45 grains
(3.0) of ^ ipecac is said to be useful. Those particularly indicated in baciUary
dysentery are antiseptics, silver nitrate and protargol in the strengths given
above, methylthionine hydrochloride gr. x (0.66) to a quart (i litre) of saturated
solution of boric acid, potassium permanganate (0.025 percent.). In amoebic
dysentery an approved irrigation is of quinine sulphate, i to 5000, gradu-
ally increased to 2 to 1000. Mercury bichloride i to 1000 to i to 6000 may
be used. Such irrigations consisting of from two to four quarts (2 to 4
litres) are given twice a day. Recently it has been found that irrigations of
copper sulphate solution of a strength of i to 6000 or less are very efl&cient.
The irrigations are given twice a day, and the colon having been filled, the
fluid is retained for twenty minutes if possible. A preliminary cleansing of
the gut by means of the injection of sterile water is advisable. This water
should be allowed to drain away before the medicated irrigation is given.
Enemata of ice water are also useful in this type of the disease. Hydrogen
dioxide, both in amoebic and bacillary dysenter}', may be injected per rectum
as a parasiticide.
Cases of tropical dysentery are reported as being favor9,bly influenced by
drinking sulphur waters and sulphur in connection with pulvis ipecacuanhae
et opii has been suggested for internal administration; 15 or 20 grains
(i.o to 1.33) of the former and five grains (0.33) of the latter may be given
every four hours. In this form of dysentery excellent results are said to
follow the administration of the fluid extract of cortex granati and of aplopap-
pus Balayhuen, a South American drug and one used there in dysentery.
In dysentery of the chronic type pure olive oil may be tried. It is said to
act as a cholagogue, and to decrease the number of bowel movements and
the tendency to intestinal fermentation and putrefaction.
Much research has been carried out in the attempt to elaborate an anti-
dysenteric serum and while in some instances favorable reports have been
made of the results of these endeavors, as yet we have no specific serum
which may be relied upon.
Before concluding it is weU to mention the surgical management of chronic
dysenteric conditions. This consists in the formation of an artificial anus
through which the bowel may be irrigated. It has been suggested that the
appendix, being opened and fastened to the edges of a colostomy wound, may
be used in this way. When rectal ulcers exist in subacute or chronic cases
they may be opened under anaesthesia, scraped and touched with caustic.
They then should be irrigated with warm normal saline solution and when
EPIDEMIC GANGRENOUS PROCTITIS. 7 1
healed the employment of irrigations of silver nitrate, i to 500 to i to 250, is
advised.
EPIDEMIC GANGRENOUS PROCTITIS.
Definition. An acute infectious disease characterized by rapidly pro-
gressing ulceration of the rectum resulting, in certain instances, in prolapse
and gangrene.
.etiology. This affection occurs in certain parts of Central and South
America, the Philippines and in islands of the Malay Archipelago. Children
are more frequently attacked than adults and in Northern South America
the latter are not affected. The disease is favored by unsanitary conditions
and malnutrition, and marked humidity is probably necessar}^ to its occiurence.
It has been attributed to the eating of unripe maize but since the affection
has been reported in regions where this cereal is unknown this cannot
be held responsible for all cases. The essential factor in the aetiology of
epidemic gangrenous proctitis is probably a micro-organism, although possibly
not a specific one, since by some it is not regarded as a distinct disease but
merely a dysentery of severe type, the lesions of which are, for some unknown
reason, confined to the colon.
Pathology. The typical lesions of this disease consist of deep ulcera-
tions of the rectal mucous membrane occurring low in the viscus between the
two sphincters or higher than this point, even involving the lining of the
sigmoid fiexure, and covered with a pseudo-membranous exudation. In
the severest forms of the affection there is rectal prolapse with gangrene
of the extruded portion.
Symptoms. The invasion of the disease is characterized by burning
and pruritus of the anal region followed by symptoms resembling those of
dysentery. The dejecta are faecal at first and ven,^ foul, later they are mixed
with mucus and finally consist merely of blood and mucus which nms slug-
gishly but constantly from the anus. Tenesmus is present, progressive