SYMPTOM A TO LOGY 



1849 



food, which is badly digested. There is often epigastric pain. 

 Vomiting occurs, but is relatively unusual in cases which are 

 taken in hand early and properly treated. The abdomen soon 

 becomes sunken and tender, especially along the course of the large 

 bowel, but this tenderness may be restricted to certain areas only 

 of that bowel. On careful palpation the thickened bowel may at 

 times be felt, but usually it is too tender to allow such manipula- 

 tion. With the numerous motions, it may be imagined that con- 

 stipation would not occur; but this is not so, for the disease may be 

 limited to the lower bowel, and as it is the involvement of the 

 rectum which causes the tenesmus and constant desire to defsecate, 

 faeces may be accumulating in the higher region of the large bowel 

 — a condition which may be recognized by the distension. Shiga, 

 indeed, describes an ascending variety of acute dysentery, which, 

 beginning in the rectum, spreads upwards along the large bowel, 

 as well as a descending variety, which usually starts in the small 

 intestine. The typical motions are composed of blood and mucus 

 only, but in bad cases they may consist of a reddish albuminous 

 fluid containing white shreds. The typical dysenteric motions have 

 no faecal smell, and microscopically show numerous micro-organisms, 

 leucocytes, and red cells, and epithelial debris and cells. Usually 

 there is some fever, ranging from 99° to 103° F. The pulse is quick- 

 ened, and in bad cases may be not merely rapid, but irregular, when 

 the heart will be found to be dilated, and perhaps haemic murmurs 

 may be heard; but these symptoms are unusual, except in grave 

 cases. The blood usually shows a diminution in the red cells, 

 and a slight polymorphonuclear leucocytosis. The lungs are usually 

 normal. Delirium is unusual. 



If the patient is to die, the motions assume the serous character 

 mentioned above, the pulse becomes rapid and irregular, the tem- 

 perature drops to subnormal, the motions diminish in number, 

 hiccough appears, and exhaustion ushers in death generally during 

 the second or third week. 



If the patient is to recover, the motions become more faeculent, 

 and the blood and mucus generally disappear, while the pain and 

 tenesmus subside, the pulse returns to normal, the tongue cleans, 

 and convalescence begins about the end of one week in mild, or of 

 one month in more severe cases. 



2. Gangrenous Dysentery. — ^This most severe type of the disease 

 may begin insidiously with some slight faeculent diarrhoea, which may 

 not attract attention until suddenly the patient becomes collapsed 

 and dies within a few hours without the passage of the typical 

 motions. Thus a prisoner may stand in the dock throughout the 

 whole day, and then die in the night from gangrenous dysentery, 

 while his sudden death may awake suspicions of suicide. 



The more usual history is that, during an attack of acute dysen^- 

 tery, the abdominal pain and tenesmus become very severe, while 

 the motions alter their characters, becoming exceedingly offensive, 

 and containing gangrenous sloughs composed of the mucosa and the 



