ART. III.

1. On the Pathology and Treatment of Dysentery, being the Gulstonian Lectures, delivered at the College of Physicians in February, 1847. By WILLIAM BALY, M.D., Physician to the Milbank Prison, and Lecturer on Forensic Medicine at St. Bartholomew's Hospital. From the Medical Gazette.-London, 1847. 8vo.

2. Observations on the History and Treatment of Dysentery and its Combinations, &c. &c. By WILLIAM HARTY, M.D., Physician to the King's Hospital and to the Prisons of Dublin. Second Edition.Dublin, 1847. 8vo. pp. 298.

3. Notes on the Pathology and Treatment of Dysentery, as observed in the European General Hospital at Bombay during the Five Years from July, 1838, to July, 1843. By C. MOREHEAD, M.D. (Transactions of the Medical and Physical Society of Bombay, No. VII. Presented April, 1845.)

4. A Dictionary of Practical Medicine. By JAMES COPLAND, M.D., F.R.S. Vol. I. Art. DYSENTERY.-London, 1844. 8vo, pp. 1056.

PERHAPS there is no single disease that has received a more voluminous illustration at the hands of writers than dysentery. And although the European practitioner of the present day has seldom occasion to witness the disease in that severe and epidemic form which called forth the observations of Sydenham, Willis, and Morton, or, at a later date, of Huxham, Zimmermann, Durandeau, or Degner, although that concourse of unfavorable hygienic conditions which in London, in the 17th century, caused dysentery to be one of the most fatal diseases in the bills of mortality,* no longer exists, still, even in temperate climates, the active causes of the diseases are but dormant, not eradicated, and are therefore not incapable of development. A famine in Ireland may recall to us, for a time, those scenes which the general misery of the population in London rendered familiar to Sydenham; and the military surgeon of our own day has witnessed in the track of the French armies, or even of our own troops in Spain and Egypt, the same devastations and the same mortality described by Pringle in the campaigns in Flanders. And although, except in such circumstances, dysentery has ceased to be a complaint daily witnessed at our own doors, this disease is still well known to the subjects of a maritime power like England, in whose vast colonies, situated in every climate and on every soil, it is certainly the most fertile in bad consequences, if not the most rapidly fatal and destructive. If cholera and yellow fever are unparalleled in the tremendous rapidity of their action, and in their resistance to the powers of medicine, dysentery is no less formidable from its oftentimes insidious nature, from its tendency to recur, and from the after-influences it exerts on particular organs, or on the system at large. Therefore almost all writers on the diseases prevalent in the colonial possessions of England have placed dysentery at the head of the list of severe affections, and have referred to it as the cause and

• The deaths from 1667 to 1692, recorded under the heads of "bloody flux" and "griping of the guts," amounted to 2000 per annum. (Heberden on the Increase and Decrease of different Diseases in London, 1801.)

origin of many of those chronic and intractable abdominal diseases witnessed so often in Europeans resident in tropical climates.

In their accounts of this disease, the best writers have differed among themselves. Pringle remarks of Sydenham and Willis, that in their description of dysentery they scarcely agree in anything beyond the name; and if the differences among more recent authors are less conspicuous, they are still numerous and important. This discordance apparently arises from the fact that dysentery, although per se a simple and uniform disease, is yet liable to constant changes in type, from differences in the causes which produce it; in other words, from alliances with other diseases. To a disquisition on dysentery, considered in this point of view, the first edition of Dr. Harty's work, published in 1805, was devoted; and the expected prevalence of dysentery at the present time in Ireland has induced him to publish a second edition, in which, with some important alterations, his former views are ably argued and sustained. The following propositions present a summary view of the conclusions he has arrived at:

"Ist. That the genuine and simple dysentery is unattended by idiopathic fever, and is never of itself contagious.

"2d. That every other form of the disease, when epidemic, is a combination of the simple dysentery either with intermittent, remittent, or continued fever.

"3d. That the combination with continued fever alone is contagious." (p. 3.) The same opinions had been previously adopted by Hoffmann, in his account of the epidemic dysentery of 1726. He distinguishes three forms -1st. Benign attacks without fever. 2d. Attacks with attendant fever, either quartan, or continued, or semitertian. 3d. Attacks attended by a most dangerous petechial fever, and this compound disease was highly contagious. Later writers have uniformly distinguished the simple and the complicated dysentery, and among these we may particularly specify Dr. Copland, who, in his elaborate article, has given us an admirable epitome of the accounts of writers, elucidated by his own experience of the disease. In the remarks we have to make, we shall follow the same order, discussing first the simple dysentery, and secondly, its combinations.

I. SIMPLE A-PYRECTIC NON-CONTAGIOUS DYSENTERY.

The greater part of the difficulties connected with the inquiry as to what is "simple dysentery," arise from the imperfect study of the morbid anatomy of the disease by the older writers. Even Morgagni has left very few dissections of dysentery, as he declined to dissect any who died of the epidemic.* Pringle gives only five detailed dissections in his

• We are inclined to regard the opinions of Morgagni in a somewhat different light than some late writers on dysentery have done. Morgagni did not from observation deny ulceration in dysentery; on the contrary, he admits its frequency. In the 31st Epistle he writes thus: "Whether there are ulcers in the large or in the small intestines, it sufficiently appears from all these observations that the intestines were really ulcerated in those dysenteric bodies from whom they were taken." (He is referring to cases detailed by Brunnerus, Valsalva, Platerus, Bossius, Fantonus, Panarolus, &c.) "Yet," he goes on to say, "in those dysenteric cases whom we have it not in our power to dissect are we also to suppose ulcerations for this reason, that, as Celsus says, they have discharged some kind of mucous portion with blood and sometimes with portions of flesh, as it were? it is worth while accurately to consider this question." He argues this question at considerable length, and seems to agree with Sennertus, who regarded these excreted membranes as mere mucous concretions, using the term "mucus" in a loose sense, to express any effusion, even of the blood. Morgagni, however, states with Tulpius, that true membrane is sometimes discharged. He sums up the argument thus: "It is more than sufficiently shown above, that those bodies which are

'Diseases of the Camp and Army,' and Dr. Hunter informs us that Pringle told him he placed little reliance on any of the dissections made in the military hospitals. Durandeau, whose work contains a most learned discussion on the causes and symptoms of epidemic dysentery, knew so little of its morbid anatomy, that he believed the seat of the disease to be chiefly in the mesentery.* Of late years, however, the morbid anatomy of dysentery, both in tropical and temperate climates, has been studied with considerable care, and in speaking of the simple dysentery we shall confine ourselves almost entirely to this single topic. The admirable lectures of Dr. Baly, who has had the opportunity of extensively observing dysentery in the prison at Milbank, contain an able discussion on the morbid anatomy, and the attempt made in them to include in one general expression all the forms described by writers is particularly ingenious and interesting. If it should appear that this attempt has not quite succeeded, or rather if, after much consideration on this subject, we hesitate to accept Dr. Baly's expression of the morbid changes, in all its extent, we do so with the admission that he has introduced into the subject a new point of discussion, and has brought into a form which admits of an accurate and defined examination the chief post-mortem appearances ascribed to dysentery. Into this examination, we now purpose to enter as fully as our limits will admit.

We must, however, first allude to the chief differences in the accounts of observers at the present time. It is almost unnecessary to say, that all agree in considering dysentery to be a disease chiefly, and in some forms, entirely of the large intestine, and, in the first instance, of its

mucous coat.

Healthy structure of the mucous membrane of the large intestine. We may briefly remind our readers that the elements of this compound mucous coat are as follows: 1st. A basement or proper membrane which doubles upon itself and forms the tubular follicles, whose orifices are seen when the surface is examined with a lens. 2d. A columnar epithelium lining all the convolutions of the membrana propria. 3d. A subjacent vascular layer containing the nutrient vessels, between the meshes of which lie cytoblasts and amorphous matter; and, 4th, certain bodies situated in the substance of the membrana propria, or even below this, and called the "solitary glands." The solitary glands, the basement membrane, and the epithelium are all extravascular, and derive their nourishment from the vascular layer beneath. The solitary glands are stated by Dr. Baly to be sometimes open and sometimes shut; to have thick walls not composed of a simple membrane, and to contain granular matter. Like the glands of the small intestine, these glands are comparatively much larger in the fœtus and in young children than in adults or in old people. In the fœtus Dr. Allen Thompson described them as simple closed vesicles. This appearance we have seen in the colon of a middle-aged man who died of Bright's disease, and who had taken elaterium before death. The glands resembled exactly the vesicles of varicella.

discharged by dysenteric patients in the form of membranes are no proof of the intestines being ulcerated, unless they are real membranes." He then asserts the same thing as regards the fleshy excrescences, and concludes that mere discharge of blood is no proof of abrasion of the mucous membrane, and he argues this point from analogical reasoning, derived from the stomach, uterus, &c. He follows, in fact, the same train of reasoning which has been used by many later writers on hemorrhage.

Traité de la Dysenterie, vol. i, p. 173. Bruxelles, 1789.

In some cases it has appeared to us that the tubular orifices can be traced over these glands; at other times, they seem only partly to cover them, becoming shortened apparently as they pass towards the centre of the gland, till they cease altogether. When the glands are much enlarged, however, the follicles are seen round, but decidedly not on them.

Morbid Anatomy. Inflammation of the solitary glands has been considered by some late writers as the first morbid condition in dysentery, and the existence of these bodies only in the large intestines has been considered to be the cause of the limitation of the disease to these parts, except in long-continued or complicated cases. On the other hand, several eminent anatomists describe the process as always one of rapid, and, in the first instance, superficial inflammation, leading inevitably and speedily to mortification, and unattended by any special disease of the solitary glands. At least, we know not how else we can interpret the description given by Rokitansky, who states that even in the first or slightest variety, the mucous membrane is swollen and red, and may be removed in the form of a pulp from beneath the furfuraceous and vesicular epithelium; while in the after stages, and in the severer varieties, the mucous membrane is transformed into a gelatinous and easily separable substance; or is in the worst form in a state of complete sphacelus, black, friable, and offensive. Lebert's description sufficiently agrees with this to prove that he has observed the same pathological state. (Physiologie Pathologique, par H. Lebert, tome i, p. 216. Paris, 1845.) Between these two extremes we should perhaps place the description given by Dr. Morehead, which, as few probably of our readers have seen, we will give more in detail.

The morbid appearances of the mucous membrane are arranged by Dr. Morehead under four heads :

1. Changes in colour and texture of the membrane. The changes in colour are described as witnessed chiefly in chronic dysentery, when there is a dark, red, gray, or black discoloration, with softening or more generally thickening of the mucous membrane. The changes in texture consist in enlargement of the solitary glands. On this point Dr. Morehead remarks:

"Under circumstances of increased secretion the mucous follicles [the solitary glands are implied by this term] of the colon become more or less prominent, and their orifices very distinct. Under these circumstances the enlargement of the mucous follicles is as yet unaccompanied by inflammatory action, but there can be no doubt that this action very quickly succeeds, and is marked by a circle of vascularity attended with softening, surrounding the orifices of the follicles, associated in some cases with thickening of the mucous membrane, in others with ulceration." (p. 139.)

2. Effusion of granules of lymph in the colon, or in the small intestines in chronic dysentery, in persons of cachectic constitutions. The effusion of lymph for some extent over the surface of the mucous membrane in shreds or tubular portions. Dr. Morehead observes that this "is a morbid lesion which takes place, but," he adds, "I do not think it can be frequent in tropical dysentery. In the cases reported by me, I find it present only in one, and that was not a case of dysentery." (Op. cit., p. 140.)

3. Ulcers of the large intestines; these are transverse or circular. "The first form, either in separate bands, or in several bands coalescing, is generally found after acute attacks of dysentery, and most commonly is associated

with more or less thickening of the walls of the intestine. The appearance of the ulcer varies according to the circumstances of stage, state of the contiguous tissues, and condition of the constitution of the subject of the disease. The bed of the ulcer may be occupied with a slough, or the slough having been thrown off, the muscular coat may be exposed, and the edges of the ulcer be irregular and thickened; or the surrounding mucous tissue may be in a more healthy state in itself and in its relation to the subjacent tissues, and the ulcer may show a tendency to cicatrize." (p. 141.)

This form of ulceration is produced, according to Dr. Morehead, by effusion of serum and lymph in the subcellular tissue of the transverse -folds: "Serum and lymph become effused into the subcellular tissue, and the relation of the mucous coat to those tissues on which its nutrition depends being thus altered, its vitality is lowered, and a predisposition to ulceration is created. The circular ulcers plainly originate in the mucous

follicles." (p. 141.)

4. The separation of the mucous membrane in shreds or tubular portions. Dr. Morehead formerly doubted the occurrence of such separation of the mucous coat, but is now satisfied that it does occur, and attributes it to diffuse inflammation of the submucous cellular tissue, "analogous to the diffuse inflammation of the subcutaneous cellular tissue."

The lesions of the other coats of the intestine are stated to be thickening from "effusion of lymph into the submucous cellular tissue ;" and from the general impairment of the nutritive process thence resulting, is produced "the easily lacerable condition not unfrequently found after death in the worst forms of the disease."

Combining together the several accounts of these and other recent writers on acute dysentery, and assuming, for the sake of the argument, that they all belong to the same form of disease, we find the chief changes in the large intestines to be an affection of a special structure, viz. the solitary glands, and ulceration commencing in these bodies; ulceration produced by effusion of serum, lymph, or pus beneath the mucous membrane; general thickening of all the coats of the intestine from effusion of lymph and hypertrophy of the muscular fibres; an acute inflammation of the general mucous membrane, producing even in the slighter form a failure in nutrition, as indicated by the pulpy state of the mucous membrane, and leading rapidly to the production of sphacelus.

All these forms have been met with by Dr. Baly, in the prison at Milbank. In the slightest or most elementary cases of dysentery, he found the solitary glands enlarged, red, and sometimes disorganized on the summits; the mucous membrane round them was also rough, and covered with an aphthous layer composed of epithelium, mixed with an amorphous matter, probably fibrin; in forms more severe, the changes were still most marked in the solitary glands, which had lost their vitality, and were converted into small sloughs; in addition, the mucous membrane in which they were imbedded was inflamed and thickened, and likewise altered on its surface; this alteration of the intermediate mucous membrane seemed to consist in a loss of vitality of part of the membrana propria; in one case these sloughs of the membrana propria formed "strips of a rough substance, which might be taken for portions of false membrane, or fibrinous exudation," but on examination with a lens, the orifices of the tubular follicles were seen on these patches. In some

XLVIII.-XXIV..

.4