Dr. A. mentions several cases of the apparent conversion of the one disease into the other, or at least of their alternating with each other. In one of these cases, the patient had three returns of rheumatism, and as many of dysentery, before he was restored to health. After adducing a variety of details, he concludes thus :-" I have so often had occasion to observe the resemblance between the two diseases, that now I regard Dysentery as a Rheumatism of the bowels, and fairly believe that the cause of both is alike." Stoll held the same opinion and uses nearly the same words to express it. He calls rheumatism and dysentery nabyμaça adeλçea, and assigns these reasons for this belief:-1. Because he often observed dysentery to supervene upon the sudden cessation of rheumatism; 2. Because sometimes the one and sometimes the other disease occurred in the same individual; and 3. Because dysentery often suddenly ceased as soon as any of the joints became swollen and painful." Richtert too declares himself satisfied of the truth of these positions, and has related several instances of the mutual conversion of the two diseases. Zimmermann‡ also may be quoted to the same effect; he mentions several cases where rheumatic symptoms immediately supervened upon a sudden arrest of dysenteric symptoms from the use of opiates and other astringents. Tissot|| and Sir George Baker§ make a similar remark. Hoffman had at an earlier period observed that, when dysentery is quickly arrested by the use of astringents and opiates, among other evil consequences, severe articular pains are apt to be induced. M. Vignes mentions that, among the numerous cases occurring in the French army around Vienna, "the alvine dejections and other dominant symptoms of the dysentery sometimes suddenly ceased upon the supervention of rheumatic pains in the knees, elbows, wrists and shoulders." Frank says nearly the same thing: "in some patients the pain of the joints seems to have freed the bowels from suffering." It will have been perceived, from the preceding statements, that the supervention of rheumatic disease in cases of dysentery has generally taken place, when the intestinal discharges have been suddenly or prematurely checked. We may hence derive a most useful therapeutic precept, viz. not to have recourse to astringent medicines at once and without any preliminary treatment. It may be here worthy of notice, that Frank has drawn an ingenious Thus : "" analogy between Dysentery and Cynanche. It is the same sort occasionally apt to induce intestinal fluxes as well as catarrhal affections. The cause would seem to be that there is present, in these morbid states, an acrimonious peccant material in the blood, which requires to be eliminated and discharged from the system; and if this be not readily carried off by the appointed emunctories-viz. the kidneys and skin-it is liable to fall upon the mucous lining of the alimentary canal or of the air-passages. Hence it is that the above diseases are not unfrequent concomitants of Oliguria or deficiency of urine, from whatever cause this originates.-Rev. + Observations, Medical and Surgical. 1794. On Dysentery. Translated by Dr. Hopson from the German. Lond. 1771. Avis au Peuple. Translated by Kirkpatrick. 1771. § De Catarrho et de Dysenteria Londinensi. 1764. 18471 Its Combinations with different Fevers. 75 of disease which attacks the throat or upper end of the alimentary canal, and the anus or its lower end: there is the strongest affinity between Dysentery and many species of Cynanche. In severe cases of the latter, we have the sense of burning, the redness, swelling, tension, the discharge of a puriform matter that is sometimes tinged with blood, the constant and painful effort of swallowing, not unlike to the tenesmus that occurs in the former." In a subsequent passage, he points out the striking similitude between the malignant forms of the two diseases.* M. Bruant, in his official report on the dysentery prevalent in the French army in Egypt, takes notice of a curious sympathy between the pains of chronic Dysentery and those of Ophthalmia: "The affection of the eyes always brought a marked relief, when it occurred in the course of longstanding dysentery; the pains of the eyes and those of the abdomen mutually took the place one of the other; the latter, however, usually re-appeared after the cessation of the former." We now pass on to the consideration of a very important point in the history of the disease. CHAP. III. Combinations of Dysentery; and first of the Intermittent and Remittent Forms. Morton,† in his excellent account of the epidemic dysentery which proved so destructive in London about the middle of the 17th century, expressly says that the bowel affection was only a symptom of the remittent fever, which was in fact the primary disease. So convinced was he, from the distinct remissions and exacerbations observable every or every second day, of the truth of this position, that he proposed that the dysentery should be designated by the appellation of spurious or colliquative Euvexns. ‡ Sydenham, it is well known, has, in more passages than one, spoken of dysentery as a "febris intraversa," or fever turned in upon the bowels. There has been a good deal of difference of opinion as to the exact meaning of this expression. But, whatever this may be, it very significantly Sydenham, in his description of dysenteric fever, has alluded to the alliance which he observed, one year, between the intestinal affection and rheumatism and cynanche conjointly: "The fever of 1671 was constantly attended, towards its decline, with extreme sickness, a vomiting of green bile, and a marked tendency to diarrhoea; while that of the following year was accompanied with pains in the muscular parts of the body, especially in the limbs, resembling those of rheumatism, and also with inflammation of the throat, but of a milder character than is present in regular quinsy. Yet both these met in the same specific fever, and both required the same method of treatment; they differed only by respect, or in consequence, of the sensible qualities of the air that prevailed at the time when these phenomena arose."-Observ. Med. IV. 4, 6. + De Febribus. Lond. 1693. Cullen, in his synopsis, includes the Febris Syneches Epidemica ab anno 1658 ad 1664, et postea ab anno 1673 ad 1691, described by Morton, under the head of tertian remittents. The reader should be on his guard not to mistake the fever termed Συνεχης, for that which is so well known by the name of Συνεχος. or common continued fever. implies the intimate connexion that this truly Hippocratic observer found often to subsist between the two diseases in question, whether this connexion is evidenced by the one becoming convertible into, or taking the place of, the other, or in any other manner. And as we know that the fever, to which Sydenham alludes under that term, was of the remittent type, the evidence of our great countryman may be fairly quoted here in proof of the subject matter we have in hand. It may be worthy of notice, en passant, that Sydenham mentions that in the first Autumn, when the dysentery he saw prevailed, many patients had no purging whatever; but that, in respect of the severity of the gripings, the intensity of the fever, the sudden prostration of the strength, and other symptoms, the disease vastly surpassed the dysenteries of subsequent years. Willis,* too, has left a very accurate description of the dysentery which proved so wide-spread and destructive in London during the years 1670, 1671. The cholera had raged, it may be observed, with great severity in the early part of the Autumn of the latter year. About the Equinox there arose an epidemic intermittent or remittent fever, which had in some cases a quotidian, in others a tertian, type. "While this fever prevailed in the villages and towns throughout the country, the bloody flux committed great ravages in London.' Willis attributes many of the characteristic features of this flux to the epidemic fever spread over the land, just as Sydenham did to his dysenteric fever; so that these two fevers would appear to be identically the same. Moseley+ testifies to the general truth of Sydenham's opinions, remarking that, as the flux conforms by the number of stools, and by its rapidity, to the degree, so it does to the state of the fever of the season, when it prevails; the stools being more frequent, and all the symptoms becoming more aggravated at those hours when the current fevers are in their exacerbation, and the reverse when these fevers are in their remissions." Now we need scarcely say that it is this very character of having distinct remissions and exacerbations every, or every other, day, that has led so many of the most experienced and enlightened observers to regard the dysentery, on various occasions, rather as one of the symptoms of a periodic fever than as a primary and essential disease. Cleghorn observed so marked a resemblance between dysentery and intermittent fever, that he was led to exhibit bark for the cure of the former. "When the fever and gripes," he says, "were regularly exasperated every day, or every other day, at stated periods, the bark has often effectually put a stop to both, especially if the exacerbation began with chilliness, and terminated in sweats: at other times it removed the fever, the flux continuing without much alteration.” Roederer, too, when speaking of the relation between the two diseases, mentions a striking instance of their combination :-" During this year, many patients were affected with intermittent fever and with dysentery * Opera Medica. Lugdun. 1676. ↑ On Tropical Diseases. Lond. 1803. 1847] Its Combination with Periodic Fevers. 77 at the same time, or with what might be called a genuine dysenteric ague. In a neighbouring town, however, the fever only prevailed epidemically; in another, which was more remote and surrounded by hills, the dysentery alone existed; while in a third and intermediate one there were but very few cases of either disease."* Clarkt also, in his description of the dysentery, or, as he calls it, the dysenteric fever of Bengal, has remarked that the intestinal affection seemed rather to be a symptom of the endemic remittent fever of the country, than an original disease. Hunter, too, says that between dysentery and the remittent fever in Jamaica, there subsists an intimate connexion, the one frequently changing into the other, and both being often complicated with various degrees of violence. Nicholl states that, at Seringapatam, the disease was frequently combined with remittent and intermittent fevers; and Trotters has remarked the same thing with respect to the coast of Africa and the West Indies. Even in our own climate, Willan has mentioned that, in the worst cases of the epidemic of 1800, (a year remarkable for cold, wet, and famine,) a considerable degree of fever prevailed from eight to ten days; the pulse 100 in the morning, and 120 in the evening; there was constant flushing of the face and coldness of the extremities; and a periodical aggravation of pain for three or four hours every forenoon was to be observed. Frank also has alluded to the frequent connexion of the two diseases. "I have seen,” says he, "dysentery follow upon periodic fever, and put a stop to it; and no sooner was the dysentery cured, than the intermittent returned as before. Indeed, the former seemed but as a symptom of the latter, and speedily vanished when the producing cause was got rid of." Dr. Wilson, in his recent interesting volume on China, says :—“ In truth, the flux ought to be considered a constituent part of the periodic fever, rather than an independent malady in most instances." The evidence now adduced is surely sufficient to prove, beyond all dispute, the not unfrequent connexion of Dysentery with Periodic Fevers ; Degner has remarked that the fever, which accompanied the dysentery which he saw, sometimes exhibited the character of an irregular tertian; and "this," he adds, "appears to me the reason why, in certain dysenteric patients, the symptoms were always worse on every third day." Huxham,† in his account of the epidemic dysentery prevalent in England in 1743, says :-"The disease was generally associated with fever, or perhaps I should rather say, it was a symptom of this fever; from its very commencement, and before the supervention of any tormina in the bowels, there was usually no inconsiderable feverish heat, with quickened pulse, and dryness of the tongue. Most frequently, it attacked with a distinct shivering, and, in many instances, it exhibited the characters of a tertian fever." * De Dysenteria Bilioso-contagiosa. Trajecti ad Rhenum. 1754. a point, be it remembered, of the highest importance, as respects the treatment of the disease. That there are some anomalies in the nature of this connexion must be admitted; they are alluded to in the following statement of our author : "Dr. Buel describes a bilious fever and dysentery as prevalent in Sheffield (State of Massachusetts), in 1796, arising from the obvious influence of marsh miasmata, and states that in some the dysentery came on while the patient was affected with the fever, in which case the type of the fever soon became obliterated, and the accompanying febrile symptoms were similar to those in original dysentery.' 'Sometimes the fever came on upon the dysentery: the type of the fever was not in this case easily ascertained, until an abatement of the dysentery took place, when, as the dysenteric symptoms subsided, the fever would appear in its proper form. The two disorders appeared to be complicated; that is, they both seemed to exist at the same time, rather than to act in alternation.' 'In this sickness,' he adds, 'there is every reason to ascribe identity of cause to the two disorders: they were circumscribed in a very striking manner by precisely the same limits, and they both began and ceased to prevail at the same time.' Dr. B. was convinced that neither of these diseases was propagated by specific contagion.' Dr. Ffirth also, in his Dissertation on Malignant Fever, says that the crew of the ship in which he sailed to Batavia (seventy-six in number), had, with the exception of eight, either marsh fever or dysentery; that the fever appeared to alternate with dysentery; when the weather was bad the latter prevailed; when good, the former. From this latter statement it is not to be inferred that the two diseases 'alternated' in the same individual, in the same sense that Dr. Buel speaks of their alternation: in this case, when one disease was prevalent, the other was not. Hargrave, too, in his History of the Walcheren Fever, states that in proportion as the autumn grew cool, these fevers (bilious remittent) abated of their ardour, and formed more easily into intermit. tents, though still irregular and of a bad kind. The dysentery was never general, though not uncommon, and it was observable that those who were seized with it usually escaped the fever, or if any had both, it was alternately; so that when the flux appeared the fever ceased, and when the first was stopped, the other returned: whence it appeared that, though the two distempers were of a different form, they proceeded from a like cause.' ”* P. 54. As exposure to cold and wet, in certain climates and under certain unsalutary circumstances, is the common cause of simple dysentery, so the complication of the disease with periodic fever may very fairly be presumed to be owing to the operation of these causes in conjunction with the agency of malaria, the prolific source of remittents and intermittents. How often, nay, how generally, are troops exposed to both of these morbific influences at one and the same time! Can we therefore be " surprised that the causes of both diseases should operate on the same individual, producing a dysentery with distinct intermissions or remissions, when we see that such a combination is frequent in those countries where the diseases themselves often exist independently of each other? This subject is explained after a similar manner by Rollo, who remarks, that the dysentery is produced in place of, or at the same time with, these fevers, when the effluvium or "The changes from intermittent fever to dysentery were very common (in the Peninsula), and seemed to suspend the intermittent for a time; but, on the removal of the dysenteric affection, the intermittent returned; in some instances, both diseases attacked the same patient at the same time, and then the dysenteric symptoms were aggravated.”—Sir James MacGregor in Med. Chir. Transactions. Vol. VI. |