1847] Its Combination with Continued Fever. 79 marsh miasma is joined in its action by the exterior application of cold and moisture, to which those affected with dysentery have been always previously exposed." Without positively asserting that marsh effluvia alone are not competent to induce dysentery, Dr. Harty very reasonably argues that "the influence of wet and cold in its production is more clearly, satisfactorily, and universally demonstrable than that of marsh effluvia, and that it is consequently more legitimate to conclude that, as dysentery can occur in every possible relation to remittent fever, either as absent or present with it, as preceding it or consequent upon it, or as remaining after the fever has ceased, or vice versa, so it cannot be likely that both are always produced by one and the same cause, more especially as those exposed to marsh effluvia are at the same time generally exposed to wet and cold." As long as the fever, which happens to be associated with Dysentery, is of a purely remittent or intermittent type, our author maintains, and with much show of truth, that the disease is not propagable from one individual to another. Most of the authors already quoted, more especially those whose experience has been chiefly in tropical countries, have unhesitatingly adopted this opinion; and some of them, confining their thoughts entirely to what they have witnessed themselves, have gone so far as to deny that dysentery ever exhibits an infectious quality. That facts, however, do not warrant so sweeping and indiscriminate an assertion must be admitted by every one, we should think, who candidly examines the evidence adduced by our author in the fourth, and second section of the fifth, chapter of his work. The former is devoted to the consideration of the Combination of Dysentery with Typhus. We shall now give a summary of its leading contents. Etmuller* alludes in a very expressive manner to the distinction of Dysentery into two forms or species, the mild and the malignant. "The former," says he, "is usually unaccompanied with fever, is not infectious, and occurs only sporadically; whereas the latter is very generally associated with a malignant, and sometimes a petechial and pestilential, fever, prevailing as an epidemic over a larger district, and multiplying itself by a virulent infection." He adds: "The tongue is whitish, and covered * Opera Omnia. Gen. 1697. †The reader might infer, from such a passage as the above, that whenever dysentery prevails in an epidemic form, it is believed to be infectious. But this is not necessarily so; the disease when associated with remittent fever may prevail epidemically, but is not infectious, as long as the fever retains the genuine periodic type. We are the more anxious that the reader attend to this point, as much of the controversy and dispute respecting the infectiousness of epidemic dysentery has arisen from a neglect of it. Such a passage as the following, taken from the extremely valuable Report of the French Academy on the Plague, might easily lead into the error in question. Alluding to the very important difference between Sporadic and Epidemic Plague, the one being admitted by almost every medical man in Egypt to be not communicable from one person to another, whereas there is difference of opinion as respects the other, the intelligent Reporter, M. Prus, goes on to say :-"There is nothing in this opinion, so generally recognised, not only at Alexandria and Cairo, but also at Smyrna and Constantinople, to surprise the medical man, who knows that sporadic dysentery is not communicable, while epidemic dysentery is often so in a high degree." with a thick slime; or, if the fever be high, it is parched and black: there is always an extreme prostration of strength. The disease spreads like the plague, is infectious, and is then propagated under the form of a malignant fever.' Zimmermann states that "the circumstance, which impresses on a dysenteric complaint the peculiar mark of malignity," is this, that, "with the causes common to the disorder at all times, others are joined which corrupt the humours, very quickly. The malignant dysentery, therefore, is that in which, either from external causes or from a putrid fomes within the body, a malignant fever supervenes; the pathognomonic signs of this species being formed by the symptoms of a malignant fever mixed with the usual symptoms of a dysentery." "It also," says he in subsequent passage, very often terminates in, or is a concomitant symptom of, putrid and malignant fevers; but, when a malignant fever supervenes on a dysentery before subsisting in the body, this is quite a different case, and constitutes a peculiar species of dysentery." Dr. Rogers, in his Essay on the Epidemic Diseases of Cork (1733), furnishes satisfactory evidence of the intimate connexion that subsisted between the endemic typhus of that city and a malignant form of Dysentery that prevailed there for several years. He remarks that the two diseases kept pace with each other, that they seemed to partake of the same common cause, and were best treated by much the same line of treatment; viz. the use of the most generous, warm, and active cordials; all antiplogistic and lowering remedies were found to be utterly inadmissible. The testimony of Sir John Pringle, also, is very strong upon the question under consideration. After stating that dysentery always becomes much aggravated towards Autumn and is then apt to "become epidemic and infectious" (from which expression it may be fairly inferred that, previously, it was sporadic and non-infectious), he gives the following instance of the pernicious effects of crowding dysenteric patients together: "The village of Feckenheim was taken for an hospital, into which about 1500 sick were sent from the camp, and of that number the greatest part ill of dysentery, by which means the air became so vitiated, that not only the rest of the patients, but the apothecaries, nurses, and other attendants, with most of the inhabitants of the village, were also infected. To this acceded a still more formidable disease, the hospital or gaol fever, an inseparable attendant of foul air from crowds and animal corruption. These two combined caused a great mortality; while on the other hand such as were seized with the dysentery and not removed from the camp, though wanting many conveniences, kept free from this malignant fever, and commonly did well." "At Feckenheim few escaped; for how mild or bad soever the flux was, this fever (the malignant) almost surely supervened the petechial spots, blotches, parotids, frequent mortifications, contagiousness, and the great mortality, set forth its pestilential nature." P. 86. Other passages might be quoted from Pringle's work in confirmation of the views here stated. For example, in one place he says: "The most fatal sort of fever, which so often attends the dysentery of the army, though not essential to it, is the hospital or gaol distemper, which at all times infects foul and crowded wards, but never so much as when they contain men labouring under a putrid disease." In another place he takes notice of Degner's epidemic, and remarks: As to the violence of the symptoms mentioned by that author, I own it exceeds anything I have observed upon the first seizure, but when a number of men, even with the most favourable cases, have 1847] Typhoid Form of the Disease. 81 been crowded into the hospitals of the army, the dysentery has then appeared with all the virulence that it did at Nimeguen. Pringle further adds, that when mortification takes place, the distemper is most contagious, whether in producing a simple dysentery, or one combined with the common hospital fever and, as he says elsewhere, It is to be apprehended that when a single person is taken ill of any putrid disease (such as dysentery), &c., and lies in a small and close apartment, he may fall into this malignant fever." " P. 87. Equally striking is the evidence furnished by Grimm, in the account which he has given of three "epidemic and eventually infectious" (epidemici et tandem contagiosi) diseases which prevailed for upwards of three years, about the middle of last century, in one district of the Duchy of Saxe Weimar. The first of these diseases was a malignant Fever, which began in December 1758, and raged throughout the Spring of 1759; it then abated somewhat of its violence; but still, during the remainder of the year, all the prevailing diseases in the place exhibited a marked tendency to assuming a type of malignancy. The fever revived in the Winter and Spring months of 1760; in the August following, it was succeeded by another and more destructive pestilence, the Dysentery. This continued its ravages to the end of November, when it again passed into the malignant fever; and so striking was the connection between the two, that, as Grimm has observed, "the same fever might well be called exanthematic at one time, and dysenteric at another, according to the season of the year in which it prevailed." "I have seen," adds he, "petechial and miliary eruptions appear on dysenteric patients; while, on the other hand, the cases of fever were often accompanied with a most offensive diarrhoea like a dysentery." It only required a change in the weather or season to cause a transmutation of the one disease into the other. In one passage, Grimm speaks of the dysentery being "associated with its own malignant fever;" and, in another, he seems to regard the former as merely a symptom of the latter; for he says that "the primary disease is the fever, arising from a peculiar vitiation of the humours, and affecting the bowels more than the other viscera of the abdomen." No candid person, one should think, after reading Grimm's description of the epidemic which he saw, can hesitate for a moment in regarding it as a compound of Dysentery and malignant Typhus. If such, then, were the case, can we be surprised at its exhibiting a virulent infectiousness?—a property or element, which, to use the author's significant expression, was "both an effect and a cause of the disease."-This remark, it will be observed, is pregnant with much meaning. The epidemic described by Roederer affords equally conclusive evidence on the point we are considering. In July of 1760, there was much intermittent fever (often of a malignant type) in the town (Goettingen) and its neighbourhood; this was followed in the next month by dysentery, which prevailed to about the beginning of Winter, when it gradually lapsed into the epidemic described by him under the appellation of morbus mucosus;—from the immense quantity of mucus that was found on dissection within the bowels, more especially the smaller ones. This acute mucous fever sometimes assumed a tertian type; but not unfrequently, more especially in the camp hospitals, it put on the characters of malignant bilious or putrid typhus. In March 1761, it became a true petechial NEW SERIES, NO. XI.-VI. G fever, accompanied with either furious delirium or coma, and constituting what Roederer calls his "febris mucosa acuta maligna." He points out the intimate connection between this disease and the dysentery which immediately preceded it; indeed, he does not hesitate to regard both as springing from the intermittent fevers which had gone before; these producing the dysentery, and the dysentery producing the mucous disease. The two last diseases resembled each other not only in their symptoms, but also in respect of many of the cadaveric changes which they left behind; viz. inflammation of the villous coat of the bowels, gangrenous eschars on the inner surface of the large ones, livid spots on the liver, induration of the pancreas, and infarction (congestion) of the lungs being mentioned as appearances common to both. Besides the Fever and Dysentery that swept away so many of the wretched inhabitants of the town which was then occupied by a hostile garrison, itself invested by an enemy in the field, another, not uncommon, offspring of an atmosphere charged with morbific effluvia from a multitude of patients crowded together and suffering at the same time from insufficient food, viz. Hospital Gangrene, made its appearance among the wounded, and added to the horrors of the place. Tissot, whom we have already quoted, says, in one passage: "If the corruption of humours, which creates malignant fevers, be united with the causes which produce dysentery, the dysentery resulting therefrom will be malignant ;" and Geach, in his observations on the epidemic dysentery at Plymouth in 1781, tells us that, in some instances, "the patients died in a day or two after the seizure, and had vibices large and very black, followed with such a degree of putrefaction and stench as to deprive almost instantaneously two female attendants of their senses, who very soon after became also dysenteric, ran through the stages of the disorder, till at length one of them died, and the other with difficulty recovered." On the subject of Typhoid Dysentery, Frank has well remarked; "Whoever will place before his eyes a faithful description of typhus, and add thereto the phenomena of dysentery in the way of symptoms, will not require a more lengthened description of this dreadful disease (asthenic malignant dysentery)." He then enumerates some of the symptoms, such as "the sudden and extreme prostration of the vital powers, small pulse, tremor of the limbs, twitching of the tendons, spasms, drowsiness, delirium, with, not unfrequently, petechia and livid spots upon the skin. This species of the disease generally prevails in camps, besieged cities, on board ships, &c. It often produces terrible ravages, and is unquestionably infectious." The details furnished by Cheyne of the dysentery which prevailed in Ireland, concurrently with the epidemic fever of 1817 and 1818, are highly instructive on many points connected with this combination of the disease. Dr. C. considered that both diseases originated from the same morbific causes. Before concluding this part of his subject, Dr. Harty alludes to the remarkable decrease in the mortality in London from Dysentery (under which name used to be included not only the "bloody flux," but also the "griping of the guts," which we read of in the writings of the old phy 1847] Very fatal in London two Centuries ago. 83 sicians) that has taken place during the last two centuries. We gather from Dr. Heberden that, in the seventeenth century, the annual number of deaths from this disease alone in the Metropolis appear never to have been less than 1000, and in some years to have exceeded 4000; whereas, in the middle of the eighteenth, it was little more than 100, and at its close not more than 20. The following passage is replete with so much interest that we are glad of the opportunity of bringing it under the reader's notice. "These facts relative to the gradual decline of dysentery, or rather of its mortality, in London, are not to be paralleled in the history of any other disease; the plague itself furnishes no parallel case, because that disease either raged violently or disappeared altogether: not so the dysentery, which has declined not so much, perhaps, in the numbers attacked, as in its positive mortality. The cause of so great an alteration in the health of the people of England, Heberden attributes to the improvements that have gradually taken place in London and all the great towns, and in the manner of living throughout the whole kingdom, particularly with respect to cleanliness and ventilation. The great influence of the assigned causes I by no means dispute; on the contrary, I am perfectly satisfied of their efficacy in the production of these happy results: in admitting this, however, I consider them to have been not the immediate but merely the remote agents in effecting such a change in the mortality of dysentery. The influence of these causes was exerted through the medium of another disease, which, if the preceding views be correct, is the great source of danger as well as contagion in dysentery: their operation was primarily exerted in mitigating and preventing contagious fever; by that means acting secondarily on dysentery, which, when separated from this its dangerous associate, is no longer an object of terror to the patient or his attendants. This opinion is supported by various facts relative to the plague, to be found in the same author. It would appear that the disease, so called, was seldom absent from London previously to the great fire of 1666, after which event it never more visited the metropolis; it appeared also that dysentery, antecedently to that period, was in general both malignant and destructive, and that shortly after there was a wonderful decrease in its frequency and severity; and though dysentery still prevailed from that time to 1692, a space of twenty-five years, it had much decreased in mortality. Morton states it to have been epidemic from 1666 to 1672, and at first exceedingly fatal (300 or 400 dying every week during its acme), though less so towards the end of that period; from Sydenham's description, dysentery appears, except occasionally, to have been devoid of contagion; and Willis's History of the Dysenteria Cruenta of the year 1670 coincides generally with this statement. "Now I consider it almost demonstrated by Heberden, that the plague of London was nothing more than the malignant contagious fever, exalted by various auxiliary aids to such a pitch of destructive violence as well to merit that name; and that the identity of the two diseases is satisfactorily supported by authority and facts. The singularly rapid decline in the mortality of dysentery, when the plague ceased to visit London, or rather when fevers lost much of their malignity, cannot but lead us to conclude that the immediate cause of this change was owing to the diminished influence and dominion of malignant fever in London. We may indeed take it as an admitted fact, that the malignity of dysentery has ceased with the disappearance of the plague. What so common among medical writers, down to the eighteenth century, as accounts of malignant and contagious dysentery? Do not their writings abound with concurrent histories of the plague or of very malignant fevers? Diemerbroeck, for example, mentions, amongst the precursors of the plague which ravaged Nimeguen in 1636: Morbi epidemii mali moris, ut erant variolæ, morbilli, dysenteriæ val le G * |