CHAPTER X. ON COLITIS AND DYSENTERY. NUMEROUS authors, Sydenham, Annesley, Parkes, Balinghall, and Morehead, have described this disease in the terrible forms manifested in tropical climates, or in military campaigns; and as formerly seen, even amongst ourselves. In our own country, however, it has very much diminished in severity and in frequency, so that it is rare to find it in its acute character, unless contracted in foreign climes, and then brought to our shores. True dysentery occurs more commonly than some of very great experience amongst us will admit; sometimes alone, and quickly fatal; or in association with general inflammatory condition of other mucous membranes; or lastly, as suddenly terminating, or aggravating varied forms of chronic disease. Particular localities and periods of the year cause the manifestation of this disease, or its complication with others in a very marked degree. This fact is shown by the observations of Dr. Latham and Dr. Baly at the Millbank prison, and is probably the reason of its more frequent occurrence in the hospitals in Southwark, than elsewhere in London. The complication of dysentery with other diseases is a very important consideration in their prognosis and treatment: thus, incipient phthisis may become altogether hopeless, and in a very short time fatal, not from the severity of the pulmonary affection, nor from strumous disease of the intestines, but from acute inflammation of the mucous membrane of the colon. Abercrombie defined diarrhoea as purging, arising from irritating substances in the canal, or from secretions poured into it; and dysentery, as acute inflammation originating in the mucous membrane of the large intestine. This distinction is probably, to a considerable extent, correct; but some forms of disease usually considered as diarrhoea, arise from catarrhal inflammation of the colon and small intestine, and after death may present scarcely any trace of abnormal change. Dysentery is generally limited to the colon, and when severe the inflammation rapidly passes into ulceration or sloughing, unless from its extent, or the previous condition of the patient, it prove fatal at an anterior stage. Several of the fatal cases recorded in this chapter terminated before extensive ulceration had taken place. Dr. Lyon, in his Crimean report, has divided dysentery into the exudative and the follicular. The former is, however, probably the earlier stage, or that preceding ulceration and sloughing. Those which have come under my own observation may be divided, practically, into three classes: 1. Those in which the inflammation of the colon was the primary disease; where it was very extensive, and sometimes, rapidly fatal. 2. Those associated with inflammation of other membranes or organs, arising at the same time, and produced apparently by a general cause, as with bronchitis, laryngitis, or pneumonia; in some instances, closely allied to pyæmia. 3. Those cases in which inflammation of the colon has hastened the fatal termination of other more chronic disease. Pathology. The dysenteric process is well described by Rokitansky, who divides it into four stages, and considers it to consist in inflammation of the mucous membrane of the colon, terminating in severe cases in sphacelus. Dr. Parkes believes that, in true dysentery, ulceration is always present, and attaches great importance to the affection of the glands; whilst Dr. Baly describes the process as sloughing, rather than ulceration. Are we then to look upon inflammation of the colon, in which there is no destruction of the mucous membrane, as true dysentery? Most will acknowledge, that death may take place prior to the ulceration or sloughing, although we rarely, if ever, find the mucous membrane entire throughout; it is probable that the diseased condition is closely allied to that of the pharynx in diphtherite; and that in severe cases, the membrane rapidly sloughs, without antecedent ulceration. In the earliest stage of dysentery, the mucous membrane becomes injected, oedematous and thickened; the mucus is scanty, and the fæces become adherent; this condition may be universal in the colon, or limited to the rectum, the sigmoid flexure, or the cæcum. 2. The secretion from the membrane becomes further changed, and a thin exudation, consisting of epithelium with a considerable quantity of granular amorphous matter, coats the intestine. It is found in patches, or lines, or spread generally, upon the surface. It has been described as dipping into the follicles; this I have myself observed, and the exudation may be seen closely incorporated with the surface of the membrane, so that it can only be separated by considerable violence. The exudation is of a greenish yellow colour, but varies somewhat according to the character of the fæces. On scraping off the effusion from the surface, the membrane beneath is found intensely congested, and often superficially ulcerated; or there may be merely minute circular patches of ulceration, and portions of the false membrane adhering at that part. This tendency to ulcerate, or to slough, resembles the diphtheritic membrane effused in the pharynx and nares. The character of the false membrane is sometimes more fibrinous. The muscular coat appears thickened, probably, because contracted; and the submucous cellular tissue is often whitish and distinct from inflammatory oedema. Dr. Baly, whilst describing this epithelial degeneration, states, that in most cases these minute adherent coverings on the surface of superficial erosions, or small ulcers, consist of thin sloughs of the mucous membrane. He believes that, in all cases, the destruction of the mucous membrane consists in a process of mortification and sloughing, and not by simple ulceration; and that the disease commences in the solitary glands of the intestines. Other parts, however, beside the solitary glands, are found to be diseased; but whether primarily or by extension, is matter of opinion. Many instances of diarrhoea are observed, in which, after death, the solitary glands were found enlarged, or minute points of ulceration presented; the whole colon may be studded over with minute ulcers, arising apparently in the glands, as is well shown in a specimen in the Guy's Museum. Dr. Baly would probably consider these to be instances of the dysenteric process in its mildest form, and that in other instances, previously alluded to, more acute changes had spread from the glands to the general surface of the membrane. Dr. Morehead has less frequently observed diphtherite in dysentery, and believes that the mucous follicles are more frequently affected than the solitary glands. * In the third stage, we find ulceration, sometimes merely as minute circular ulcers, as before described; more frequently the ulceration is much more extensive, often oval in form, and placed in the transverse axis of the intestine; the edges raised and much injected, the margins irregular and undermined, and the floor formed by the cellular or muscular coats. These ulcerations gradually extend so as to coalesce, till at last nearly the whole. of the mucous surface is destroyed, except here and there prominent isolated portions, which become intensely congested, and resemble polypoid growths. In severe cases the whole colon, from the cæcum to the rectum, is in this condition, or greater spaces intervene, or ulcers are only found in the rectum, sigmoid flexure, or cæcum. It sometimes happens, that the ulceration extends through the muscular and the peritoneal coat, leading to fatal peritonitis from perforation, but this is a rare occurrence; or, the coats of the intestine become sinuous abscesses, so that on dividing a prominent portion of mucous membrane, between two ulcers, several drachms of pus escape. This extensive suppuration very different from the small local collections of pus, which sometimes form in the substance of the mucous membrane after follicular or glandular inflammation, where small eminences about half an inch in diameter are observed, covered by thin layers of mucous membrane. This is a less general and less severe form of inflammation of the colon, which I have several times observed. is Dr. Morehead gives an instance of fæcal abscess, in the right iliac fossa, from perforation of the cæcum in dysentery. If the acute symptoms have subsided the injection is less deep in colour, and often gradually becomes grey; the edges of the ulcers become rounded and less prominent; the surface has a smooth and fibrous appearance; ulcerative action has been checked, and cicatrization has commenced. The healing process may go on, so that the cicatrix has an irregular puckered appearance. The base of the cicatrix is formed by fibro-cellular * Morehead on Diseases of India. tissue, but the gland structure is not reproduced. The contraction of the cicatrix sometimes produces considerable constriction of the intestine, and occasionally tends to fatal obstruction. Very frequently above the cicatrix all the coats become hypertrophied, showing that there has been much impediment. Dr. Wilks has mentioned to me a case in which the cicatrix presented a growth at its margin, evidently of a carcinomatous character, indicating a greater tendency to heterologous deposit in new tissue. In a fourth stage of dysentery the mucous membrane presents a grey ashy appearance, and considerable portions of it constitute ragged and semi-detached sloughs. The sequele of dysentery, unless death have resulted from the severity of the disease, are:-1. Perforation of the intestine and fatal peritonitis. 2nd. Fæcal abscess. 3rd. Gradually increasing exhaustion from the destruction of the mucous membrane. 4th. Constipation, arising from the contraction of cicatrices, leading to very troublesome and irregular condition of the bowels, and sometimes fatal obstruction. 5th. Pyæmia and suppuration in the substance of the liver, from the absorption of pus, as described by Dr. Budd, in his work on Diseases of the Liver; this last result I have only once observed at Guy's, in simple English dysentery, which is nearly in accordance with the experience of Dr. Baly, at the Millbank Penitentiary, and shows that whilst the disease may be the same in its general character and pathology with tropical dysentery, there is some modifying cause. Symptoms.-A sensation of coldness in the loins, chilliness, or actual rigor, is followed by a loose evacuation from the bowels; this is repeated, and the evacuations become scanty, but often accompanied with tenesmus, or a forcing sensation as if the intestine retained its fæcal contents. With this there may be slight pain or soreness in the iliac region or position of the transverse colon, and even severe griping. The amount of febrile disturbance, and the alteration of the tongue, are very varied, but the latter symptoms do not always exist. In very mild cases the energies and mental activity are as usual, but the face becomes pallid, and the strength is not equal to accustomed duty. This condition may continue for several days, the patient |