The Understanding and Treatment of Dysentery
During the late eighteenth and early nineteenth centuries, the understanding and treatment of dysentery were quite different from those today, the crucial consideration being that physicians did not yet understand — nor would they for some time — that the illness is caused by pathogens. Although their deductions concerning the causes of dysentery were thus more a collection of common circumstances that seemed to accompany its appearance, their description of the symptoms and course of the illness were, not surprisingly, sometimes quite detailed. Unfortunately, their suggestions for cures were guided by their failure to understand the causes, and could and in fact often did aggravate rather than ameliorate the symptoms, prolong the course, or intensify its severity.
Both Auguste and Caroline were said to have died of Ruhr, an illness that in England was known as dysentery.  Physicians in both countries, moreover, generally differentiated between Ruhr and dysentery, on the one hand, and Durchfall and diarrhea, on the other. Whether their pathology was entirely accurate according to modern standards is less the issue here than that, according to the symptoms they observed, the illness at issue was what they understood to be dysentery.
Because there was copious literature on the subject, and because the illness was not uncommon (indeed, it is alleged to have contributed to Prussian losses in the campaign of 1792), physicians were generally familiar with the symptoms and their association with this illness.
Hence one can with a fair degree of certainty assume that both Auguste and Caroline exhibited such symptoms. Whether such symptoms genuinely confirm the presence of what modern medicine calls dysentery in both instances is a different issue. For our purposes here, and assuming the symptoms were accurately discerned, one might reasonably assume that they did indeed confirm the presence of what physicians at the time understood as dysentery.
That said, because, physicians also understood there to be different iterations of the illness, so also were treatments to be different. That is, there was no one generally accepted treatment for all the iterations of dysentery, a factor complicating attempts to assess how closely a physician or attending person (e.g., Schelling) adhered to an accepted treatment for a certain form of the disease. In any event, German physicians often (though not always), in language reflecting in part that of John Brown, referred to hypersthenic and asthenic dysentery, and in some cases (Ernst Horn, to be referenced later) to subgroups of those two types.
The publications below generally increase in complexity, thoroughness, and length as one progresses from one piece to the next; readers can choose to examine only certain pieces or, depending on interest, all of them.
I. Contemporary Definitions — II. Christoph Wilhelm Hufeland, Caroline’s personal physician in Jena, The Practice of Medicine (1836) (a view from someone closely associated with Caroline); — III. William Buchan, Domestic Medicine (1804) (a view from England); — IV. Adolph Henke, Textbook of Specialized Pathology (1808) (a lengthier view from a contemporary German physician who also distinguishes between hypersthenic and asthenic dysentery).
(1) Adelung 3 (1798), 1206:
Die Ruhr, plur. die Ruhren, from the verb rühren . . . (3) An illness among human beings and animals that consists in an unusually heavy flux or flow of the intestine, though earlier every intestinal flux, and even the purging of the belly was called Ruhr. White Ruhr, an intestinal flux of normal color in which the digested foodstuffs flow off with a thin, watery consistency, and which in the case of human beings is most frequently called Durchfall [lit. “through fall”], Durchlauf [lit. “through run”], and diarrhea. Red Ruhr, also called simply Ruhr as such when blood is also discharged amid quite severe pain; the designation “dysentery” derives from the Greek and Latin dysenteria [dys- “bad, abnormal, difficult” + entera “intestines, bowels”].
Note: In the latter case [Ruhr], it derives initially from the archaic meaning of the verb, since it was also used for “flow, flowing,” so that Ruhr actually refers to the flow, and in the narrower sense intestinal flow.
(2) The New and Complete Dictionary of the German and English Languages composed chiefly after the German Dictionaries of Mr. Adelung and of Mr. Schwan, ed. John Ebers, 3 vols. (Leipzig 1796–99), 2:1105:
Ruhr, die, a Lask [diarrhea or flux] or Looseness, a Flux with Wringing of the Bowels. Die rothe Ruhr, the Dysentery or Bloody-Flux; die weisse Ruhr, the Diarrhea, a Flux without Blood.
(3) Félicité Ducrest de Saint-Aubin, Madame de Genlis, The traveller’s companion; being a collection of such expressions as occur most frequently in travelling, and in the different situations of life. In four languages: English, German, French and Italian (Leipzig 1804), 158, dialogue 21, “Between a Physician, a Waiting-woman, and a sick Person at an Inn”:
I have a diarrhea or a dysentery. Ich habe den Durchfall, die Ruhr.
(4) Robert Hooper, A Compendious Medical Dictionary containing an explanation of the terms in Anatomy, physiology, surgery, practice of physic, material medica, chemistry, &c. &c., 2nd ed. (London 1801), s.v. “dysentery”:
Dysentery (Dysenteria, ae, f. δυσεντερια, from δυσ, difficultly, and εντερα, the bowels). Flux. A genus of disease in the class pyrexia and order profluvia of Cullen’s nosology. It is known by contagious pyrexia; frequent griping stools; tenesmus [a distressing but ineffectual urge to evacuate the rectum or bladder]; stools, chiefly mucous, sometimes mixed with blood, the natural faeces being retained or voided in a hardened state; loss of appetite, and nausea.
II. Christoph Wilhelm Hufeland, Enchiridion medicum oder Anleitung zur medizinischen Praxis: Vermächtniss einer fünfzigjährigen Erfahrung, 6th ed. (8th printing) (Berlin 1842) (1st ed. 1836); translated by Robert Nelson as Enchiridion Medicum: or The Practice of Medicine, 4th ed. (New York 1855), 363–67, also addendum, 40:
Diagnosis. Constant urgency to go to stool, tenesmus, violent abdominal pains, fever; only mucus and blood, but no faeces in the stools. Therefore the disease is not properly a flux but a constipation, an essential difference, and the reverse of diarrhoea. In diarrhoea nuisible [harmful, damaging, injurious] intestinal impurities are evacuated; in dysentery they are impeded and retained. Diarrhoea can get well by itself, not so dysentery. As soon as feculent impurities are discharged in dysentery, the disease may be said to be cured.
The course of the disease varies. Sometimes it is announced by previous symptoms, sometimes not. It may be of short duration, sometimes long, even passing into chronic dysentery. The precursory symptoms are frequently diarrhoea or dull pains in the abdomen. It commences by a cessation of bilious stools, which is followed by tenesmus with small mucous evacuations (white dysentery), which on account of increasing irritation subsequently gets mixed with blood (red dysentery). In the beginning there are febrile motions, which soon cease in a slight attack of the disease.
When the malady is severe, the pains continue to increase and the stools may augment to 100 in 24 hours, and their fetor [stench] increases with the fever. This aggravation is owing to the addition of inflammation, or to an excess of bilious putrid matter, or to exhaustion. Death ensues by inflammation and gangrene, or by exhaustion. The signs of gangrenous mortification are: sudden cessation of pain after having violently raged, a sunken-in countenance, cold extremities, small intermittent pulse, the evacuations are highly offensive, and are passed without consciousness. Amelioration is indicated by diminution of the pains and fever, and the evacuations becoming feculent.
Violent dysentery is frequently succeeded by paralysis, chronic diarrhoea, nervous fever, and lingering fever.
Pathogenesis. The proximate cause is a violent convulsive irritation of the large intestines, the secretion of mucus pathologically increased and rendered acrid. It is therefore not primarily an inflammation, but inflammation may grow out of it by an increase of irritation.
It is very similar to that of catarrhal irritation of the mucous membrane of the bronchia; (when in more severe coryza [acute inflammation of the upper respiratory tract] and cough, streaks of blood are mixed with the mucus, and it is apt to pass into inflammation merely by an increase of irritation), — a catarrhus or rheumatismus intestini crassi.
This local irritation may have various remote causes: an unusual excitement or irritation of the organ. The most common cause is suppressed action of the skin (antagonistic irritation), with increase of quantity and acrimony of bile. On this account it is frequently epidemical, in August and September, after great heat of the day (which renders the bile more acrid and increases it), followed by cool evenings and nights, which arrest the perspiration. It therefore has always a bilious rheumatic character.
In severe epidemical dysentery, especially when it assumes a putrid character [being in a state of putrefaction], a contagium dysentericum may be developed, which, however, seems to be only local, adhering to the intestinal evacuations, and rendering their emanations dangerous.
There is also an endemic disposition to this disease. Low, moist, marshy regions, such as predispose to intermittent fevers, incline also to dysentery; hence they generally prevail in such places.
Besides these causes of primary essential dysentery, there are also others which may create it symptomatically and secondarily, either by a violent local irritation, as caustic poisons, worms; or by an exceedingly increased irritability of the intestinal canal, as a haemorrhoidal congestion, metastases; or consensually, as from difficult dentition.
Therapeutics. The fundamental indication is to assuage the excited state of the colon by removing the irritant cause and the increased irritability. The next thing to be done is to consider the respective characters of the different irritations.
The rheumatic-bilious character is of the most frequent occurrence, and is common to the autumnal dysentery. In this kind of dysentery we have in general only need of the following remedies: an emetic of ipecacuanha [containing an emetic alkaloid extracted from ipecac root] in the commencement; then a laxative mixture of manna and tamarinds, with a small addition of sulphate of soda and tartar emetic, continued for 24 hours; should no amelioration ensue, a mucilaginous emulsion containing small doses of opium.*
Pearl-barley, water-gruel, gum-water, given at the same time as beverage, the abdomen and back clothed in flannel, and an embrocation of antispasmodic ointments with opium to the abdomen. Ipecacuanha given in the beginning as an emetic is generally necessary and of great benefit for the after treatment There is but one exception to this rule: it is when the patient has no signs of saburra [foul granular matter deposited in the alimentary canal by the decomposition of food], and the stools contain no feculent matter.
*[see Hufeland’s addendum The Three Cardinal Means of the Art of Healing, 40, on the use of opium in dysentery:
The use of opium in dysentery merits our particular attention. — Here also the cases must be well distinguished. He, who would give opium in a bilious or inflammatory dysentery, would kill his patient. On the contrary it is the only salvative in a purely rheumatic dysentery. That dreadful rheumatic dysentery engendered by damp and cold, which killed so many thousands of the Prussian army in the campaign of 1792, as long as it was treated with rhubarb, at that time in usage, only became controllable, and was annihilated, when opium was universally used against it. But I advise an emetic of ipecac to be given before resorting to the use of opium; and to use it not in a full dose at once, but in small frequently repeated doses mixed with a mucilage or an emulsion; since a suppression of dysentery may be caused which is always injurious; while the intention must be only to gradually diminish the increased secretion of mucus, the escape of blood, and to resolve the spasm, which locks up the foecal matter, all which is best attained by the latter method.]
Should no improvement follow this treatment, it is because of the following cases, which must be carefully distinguished.
1. The fever increases, the pulse becomes full and hard; or the patient is young and plethoric, the pains are severe, or confined to one spot; the abdomen is tense and painful to the touch. Here is incipient inflammation, and immediate need of venesection [the letting of blood]; or of leeches when the case is light. At the same time an oily emulsion is to be given, to which opium may be added as soon as venesection has abated the pulse.
2. Or the pulse is not full, but the tongue is unclean, with many other indications of gastric impurities, which are generally of a bilious nature. In this case the primae viae [first or main passages, here: the alimentary canal, the bowels] are to be cleared, carefully distinguishing whether the stools contain feculent matter or not. If they do, the above-mentioned tamarind mixture is to be given along with mucilaginous drinks, until the stools become watery. But in the second case, when the evacuations are not feculent, another emetic must be prescribed which will usually render them feculent. Should this be unavailing, rhubarb (vide No. 191 [an apothecary concoction]) or calomel [mercurous chloride, used as a purgative] with opium must be tried.
3. Or there exist neither signs of inflammation nor of gastric impurities; but the patient suffers violent pains with tenesmus, the stools are scanty, watery, mucous or bloody. Such a case is caused principally by cold; its character is rheumatic, a real rheumatismus intestinorum. Here opium with gum arabic administered internally, externally, and in clysters are the chief remedies; at the same time a vesicatory [blistering agent] to the abdomen and warm baths are proper.
4. Or finally, the case is marked by extreme prostration from the beginning (dysent. nervosa adynamica). Here, the foregoing remedies (opium and mucilages, also emetics and purgatives when necessary) must be combined with nerviness [drug used in nervous diseases], valerian, angelica [herb], arnica [herb], wine, and warm baths. If it assumes a putrid character, which is recognised by extreme weakness and a cadaverous odor of the stools, arnica (1 scruple of the powder every 2 hours, or a decoction off 1/2 ounce to 8 ounces of fluid) and wines are particularly recommendable.
Sometimes, however, the dysentery continues obstinate and will not cease, though it diminishes in force. Here, experience has shown that the following remedies are very efficacious: 10 grains of powdered nux vomica [strychnine] daily, or 2 to 4 grains of the extract; sulphur, calomel, even sublimate in minute doses (1/8 grain to 4 ounces of water with 3 ounces of mucilage of gum arab. and 12 drops of laudanum [tincture of opium], one table spoonful every 2 hours), which may also be given in injections, though in smaller doses, as the 1/16 of a grain with opium and mucilage. In such a case too, when all other means fail, the vitrum ceratum antimonii, in 1/2 or 1 grain doses, which according to the experience of the most approved practitioners, has been used with the greatest benefit; also wax, made into emulsion with the yolk of eggs; warm baths, especially in rheumatic dysentery.
If dysentery becomes chronic, arnica, the root (1 scruple of the powder every 2 or 3 hours) is the principal remedy. But denudation of the intestines by loss of mucous membrane, and the rawness thereby created, deserves great attention; for which the frequent use of salep-mucilage is the most efficient, and will often alone suffice. In obstinate cases it is best to hold to two ideas: that of weakness, and that of a chronic passive inflammatory state of the mucous membrane of the rectum. In the first, especially when accompanied by lingering fever, rad. columbo, lignum campechiense, and simaruba [tree whose root was popularly used to treat various symptoms of dysentery] are most beneficial; in the second, injections of 1/16 of a grain of sublimate with opium and mucilage or starch.
Suppressed dysentery. This name designates a case, when the dysenteric evacuations have been suddenly stopped by violent means, as by red wine, brandy, large doses of opium, producing bad attacks. They are of a double kind: acute or chronic. First are inflammatory or spasmodic; known by violent pains, distention of the abdomen, totally suppressed discharges from the intestines, great anxiety, spasms.
Here the discharge is to be restored as promptly as possible by oily remedies, manna, calomel, especially by frequent emollient clysters and cataplasms; where the character is more inflammatory, leeches; when very spasmodic, hyoscyamus [plant of the Nightshade family], tepid baths. The chronic consequences are obstinate rheumatisms, paralysis, hydrops [accumulation of watery fluid in cells and tissues]. Here resolvents and purgatives must be administered, and the newly generated diseases treated at the same time.
After every dysentery the use of bitter roborants [strengthening medicines], flannel around the abdomen, and careful diet are necessary.
The cure of the symptomatic and chronic dysentery is effected in conformity to the causes. Dysentery caused by worms, vide helminthiasis; by dentition, vide diseases of children; by metastases and ulceration or organic disorders of the intestinal canal, vide diarrhoea chronica.
The first indication is always to assuage the irritation, and then to remove the irritant cause. In every chronic dysentery we have carefully to examine, whether a fistula of the rectum may not be the concealed cause.
The best preservative against dysentery is a flannel vest worn around the abdomen. Ripe fruit, when not eaten in excess, is not injurious.
III. William Buchan, Domestic Medicine: or, a Valuable Treatise on the Prevention and Cure of Diseases by Regimen and Simple Medicines (Leominster 1804), 217–22:
Of the Dysentery or Bloody Flux
This disease prevails in the spring and autumn. It is most common in marshy countries, where, after hot and dry summers, it is apt to become epidemic. Persons are most liable to it who are much exposed to the night air, or who live in places where the air is confined and unwholesome. Hence it often proves fatal in camps, on shipboard, in jails, hospitals, and such like places.
Causes. The dysentery may be occasioned by any thing that obstructs the perspiration, or renders the humours putrid; as damp beds, wet clothes, unwholesome diet, bad air, &c. But it is most frequently communicated by infection. This ought to make people extremely cautious in going near such persons as labour under the disease. Even the smell of the Patient’s excrements has been known to communicate the infection.
Symptoms. It is known by a flux of the belly, attended by violent pain of the bowels, a constant inclination to go to stool, and generally more or less blood in the stools. It begins like other fevers, with chilliness, loss of strength, a quick pulse, great thirst, and an inclination to vomit. The stools are at first greasy and frothy, afterwards they are streaked with blood, and at last have frequently the appearance of pure blood, mixed with small filaments resembling bits of skin. Worms are sometimes passed both upwards and downwards through the whole course of the disease. When the patient goes to stool, he feels a bearing down, as if the whole bowels were falling out, and sometimes a part of the intestine is actually protruded, which proves exceeding troublesome, especially in children. Flatulency is likewise a troublesome symptom, especially towards the end of the disease.
This disease may be distinguished from a diarrhoea or looseness by the acute pain of the bowels, and the blood which generally appears in the stools. It may be distinguished from the cholera morbus by its not being attended with such violent and frequent fits of vomiting, &c.
When the dysentery attacks the old, the delicate, or such as have been wasted by the gout, the scurvy, or other lingering disease, it generally proves fatal. Vomiting and hiccuping are bad signs, as they shew an inflammation of the stomach. When the stools are green, black, or have an exceeding disagreeable cadaverous smell, the danger is very great, as it shews the disease to be of the putrid kind. It is an unfavourable symptom when clysters are immediately returned; but still more so when the passage is so obstinately shut, that they cannot be injected. A feeble pulse, coldness of the extremities, with difficulty of swallowing, and convulsions, are signs of approaching death.
Regimen. Nothing is of more importance in this disease, than cleanliness. It contributes greatly to the recovery of the patient, and no less to the safety of such as attend him. In all contagious diseases the danger is increased, and the infection spread, by the neglect of cleanliness; but in no one more than this. Every thing about the patient should be frequently changed. The excrement should never be suffered to continue in his chamber, but removed immediately and buried under ground. A constant stream of fresh air should be admitted into the chamber; and it ought frequently to be sprinkled with vinegar, juice of lemon, or some other strong acid.
The patient must not be discouraged, but his spirits kept up in hopes of a cure. Nothing tends more to render any putrid disease mortal, than the fears and apprehensions of the sick. All diseases of this nature have a tendency to sink and depress the spirits, and when that is increased by fears and alarms from those whom the patient believes to be persons of skill, it cannot fail to have the worst effects.
A flannel waistcoat worn next the skin has often a very good effect in the dysentery. This promotes the perspiration without over heating the body. Great caution however is necessary in leaving it off. I have known a dysentery brought on by imprudently throwing off a flannel waistcoat before the season was sufficiently warm. For whatever purpose this piece of dress is worn, it should never be left off but in a warm season.
In this disease the greatest attention must be paid to the patient’s diet. Flesh, fish, and every thing that has a tendency to turn putrid or rancid on the stomach, must be abstained from. Apples boiled in milk, water pap, and plain light pudding, with broth made of the gelatinous parts of animals, may constitute the principal part of the patient’s food. Gelatinous broth not only answers the purpose of food, but likewise of medicine. I have often known dysenteries, which were not of a putrid nature; cured by it, after pompous medicines had proved ineffectual.
Another kind of food very proper in the dysentery, which may be used by such as cannot take the broth mentioned above, is made by boiling a few handfuls of fine flower, tied in a cloth, for six or seven hours, till it becomes as hard as starch. Two or three table-spoonfuls of this may be grated down, and boiled in such a quantity of new milk and water, as to be of the thickness of pap. This may be sweetened to the patient’s taste, and taken for his ordinary food.
In a putrid dysentery the patient may be allowed to eat freely of most kinds of good ripe fruit; as apples, grapes, goosberries, currant-berries, straw-berries, &c. These may either be eaten raw or boiled; with or without milk, as the patient chooses. The prejudice against fruit in this disease is so great, that many believe it to be the common cause of dysenteries.
This however is an egregious mistake. Both reason and experience shew, that good fruit is one of the best medicines both for the prevention and cure of the dysentery. Good fruit is in every respect calculated to counteract that tendency to putrefaction, from whence the most dangerous kind of dysentery proceeds. The patient in such a case ought therefore to be allowed to eat as much fruit as he pleases, provided it be ripe.
The most proper drink in this disorder is whey. The dysentery has often been cured by the use of clear whey alone. It may be taken both for drink and in form of a clyster. When whey cannot be had, barley-water sharpened with cream of tartar may be drank, or a decoction of barley and tamarinds; two ounces of the former and one of the latter may be boiled in two English quarts of water to one. Warm water, water gruel, or water wherein hot iron has been frequently quenched, are all very proper, and may be drank in turns. Camomile tea, if the stomach will bear it, is an exceeding proper drink. It both strengthens the stomach, and by its anticeptic quality tends to prevent a mortification of the bowels.
Medicine. At the beginning of this disease it is always necessary to cleanse the first passages. For this purpose a vomit of ipecacuanha [containing an emetic alkaloid extracted from ipecac root, often prepared as a syrup] must be given, and wrought off with weak camomile tea. Strong vomits are seldom necessary here. A scruple, or at most half a drachm of ipecacuanha, is generally sufficient for an adult, and sometimes a very few grains will suffice.
The day after the vomit, half a drachm, or two scruples of rhubarb, must be taken; or what will answer the purpose rather better, an ounce or an ounce and an half of Epsom salt. This dose may be repeated every other day for two or three times. Afterwards small doses of ipecacuanha may be taken for sometime. Two or three grains of the powder may be mixed in a table spoonful of the syrup of poppies, and taken three times a-day.
These evacuations, and the regimen prescribed above, will often be sufficient to effect a cure. Should it however happen otherwise, the following astringent medicines may be used:
A clyster of starch or fat mutton-broth, with thirty or forty drops of liquid laudanum [tincture of opium] in it may be administered twice a-day. At the same time an ounce of gum-arabic, and half an ounce of gum-tragacanth, may be dissolved in an English pint of barley water, over a slow fire, and a table-spoonful of it taken every hour.
If these have not the desired effect, the patient may take, four times a-day, about the bulk of a nutmeg of the japonic Confection [Buchan, ibid., 423: Take Japan earth, three ounces; tormentil root, nutmeg, olibanum, of each two ounces; opium dissolved in a sufficient quantity of Lisbon wine, a drachm and a half; simple syrup and conserve of roses, of each fourteen ounces. Mix and make them into an electuary], drinking after it a tea-cupful of the decoction of logwood.
Persons who have been cured of this disease are very liable to suffer a relapse; to prevent which, great circumspection with respect to diet is necessary. The patient must abstain from all fermented liquors, except now and then a glass of good wine; but he must drink no kind of malt liquor. He should likewise abstain from animal food, as fish and flesh, and live principally on milk and vegetables.
Gentle exercise and wholesome air are likewise of importance. — The patient should go to the country as soon as his strength will permit, and should take exercise daily on horseback, or in a carriage. He may likewise use bitters infused in wine or brandy, and may drink twice a-day a gill of lime-water mixed with an equal quantity of new milk.
When dysenteries prevail, we would recommend a strict attention to cleanliness, a spare use of animal food, and the free use of found ripe fruits, and other vegetables. The night air is to be carefully avoided, and all communication with the sick. Bad smells are likewise to be shunned, especially those which arise from putrid animal substances. The necessaries where the sick go are carefully to be avoided.
When the first symptoms of the dysentery appear, the patient ought immediately to take a vomit, to go to bed, and drink plentifully of weak warm liquor, to promote a sweat. This, with a dose or two of rhubarb at the beginning, would often carry off the disease. In countries where dysenteries prevail, we would advise such as are liable to them, to take either a vomit or a purge every spring or autumn, as a preventive.
IV. Adolph Henke, Handbuch der speziellen Pathologie, 2 vols. (Berlin 1808) (Textbook of specialized pathology), 2:251–67:
1031. The designation dysentery is applied to a mucous, bloody intestinal flow with vehement abdominal pains, a constant urge to evacuate the bowels, involuntary bowel evacuation, and fever.
The views of both earlier and more recent physicians differ concerning whether the primary element of this illness consists in the fever or the local affliction of the intestines. — This difference of opinion, however, seems to be based on a misunderstanding insofar as the conclusions derive in their own turn from different perspectives.
1032. With respect to the nosological determination of the form of this illness, it is doubtless the specific localized illness affecting the intestine with the attendant symptoms that constitutes the primary element insofar as a dysentery fever lacking such is as little dysentery as a fever — of whatever sort — lacking an inflammation of the lungs can be called pneumonia.
There are, moreover, less severe dysentery cases quite lacking fever, and chronic cases no longer attesting fever following the acute stage. Both would be accorded the designation dysentery as long as the essential symptoms of the illness of the intestinal tract (enteron) are present.
1033. From the prognostic and therapeutic perspective, however, one can very well defend the assertion that the fever arising with dysentery, as an expression of the overall malady, is the most important element, since the determination of the therapy generally depends on the character of that fever.
Physicians from every age, moreover, have drawn attention to the feverish nature of dysentery to guide the harmful notion concerning the merely localized nature of this illness (i.e., based on gastric impurities, acrid materials, etc.). [Thomas] Sydenham called dysentery febrem ad intestina conversam, and Friedrich Hoffmann, Peter Frank, and [Ernst] Horn largely concur with this statement.
1034. [Christian Gottlieb] Selle, Peter Frank, and others have justifiably pointed out that the feverish nature of the illness is often misdiagnosed because the chills, overheating, and feverish pulse are often not discerned at the beginning of the illness; but the change in self-awareness, exhaustion, skin dryness, thirst, the so-called crises of sweats and urine, the nocturnal exacerbations not infrequently demonstrate clearly enough the overall nature of the malady even when feverish symptoms are not present. Although it is in the meantime true that some patients ill with dysentery are quite without fever, in that case the localized affliction of the intestinal tract can only be quite mild.
1033. The course of the illness is usually as follows:
Precursory signs appear for several days in a row, specifically — apart from those preceding every fever — also signs of a disrupted function of the intestinal tract, a lack of appetite, pressure in the abdomen, nausea, an inclination to vomit, the evacuation of mucous and bilious material, colic with severe pain in the navel area, diarrhea with evacuations of mucous materials, though occasionally also constipation.
1036. What then follows is that with which in other cases the illness begins, namely, vehement stomach pains, frequent urge to evacuate the bowels, involuntary evacuation of the bowels, whereby the evacuation becomes increasingly abnormal to the point that finally no intestinal excrement at all is eliminated. The evacuation then consists of whitish, mucous, occasionally pus-like and often also more or less blood-colored, occasionally also greenish and almost always specifically vile-smelling liquids. Every evacuation is preceded by a renewed attack of severe, biting abdominal pain, and the excretion itself comes about with straining, burning, and pain in the rectum and anus.
The quantity of excreted material is always small, occasionally even wholly insignificant, since when severe this illness is accompanied by fifty, sixty, even a hundred bowel evacuations in a single day, though such material can also be quantitatively quite considerable. The secretion of blood in the intestinal tract can occasionally become so strong that pure, unadulterated blood is excreted, often in considerable quantities. —
Apart from such mucus and blood, however, filament-like or skin-like masses, clumps with the consistency of soap and tallow, polypous concrescences, occasionally pseudomembranous material (often incorrectly viewed as ragged skin filaments from the intestine), though most frequently concrescences of small pieces or flakes are discharged. All are products of the lymph that has separated or been sweated out in the intestinal tract.
1037. All these symptoms last for a shorter or longer period of time, with higher or lower intensity depending on whether the illness itself is vehement or mild and is inclining toward a positive or negative outcome. In the most favorable cases, everything runs its course within seven to nine days, with the symptoms of the overall malady and intestinal affectation gradually abating and the excretory function becoming normal again. The deviations and additional symptoms, such as a modification of the fever, are most conveniently considered under the rubric of the following varieties of dysentery.
Categorization of Dysentery
1038. Like every illness caused by abnormal vitality, dysentery can be divided into hypersthenic and asthenic varieties, each of which encompasses several subgroups designated by various names according to the modification of the form and the simultaneous affliction of other organs.
The lesser degrees of hypersthenic dysentery constitute what is known as benign dysentery. Neither the fever nor the symptoms of intestinal affliction reach a high degree. Occasionally fever can hardly be discerned. The pain is not as severe, occurs only just before evacuations, and the urge to evacuate and the number of evacuations are not as considerable; the ill person does not become so exhausted, and the illness itself runs its course within a week.
1039. The higher degrees are characterized by continuous fever, strong chills and febrile heat, moderately quick, initially full and strong pulse, which, however, afterward is often harshly and tightly contracted. Pains in the lower intestine are extremely vehement, the body tense, painful to the touch, and with vehement burning in the rectum and perineum. The urinary organs are also afflicted, whence dysuria [difficult or painful discharge of urine] and strangury [slow and painful spasmodic discharge of urine drop by drop], the urine itself quite low in quantity, fiery red or completely watery.
Significant blood evacuations occasionally come from the intestinal tract, which also provide relief. But if the illness is left to itself, or aggravated by inappropriate, irritating treatment, the intestines become inflamed, and if the illness becomes more severe yet, one experiences a transition into indirect weakness and mortification with the usual symptoms. Apart from the symptoms already considered, a diagnosis assesses the general criteria of hypersthenia and the increase of the illness after aggravating treatments.
1040. Just as certain as hypersthenic dysentery can occur not just individually, but also epidemically, something only ignorant, crude “Brownianism” could deny, so also, however, is dysentery far more frequently of an asthenic nature.
The milder degrees of asthenic dysentery have been variously classified:
(a) What is known as rheumatic dysentery. Rheumatic fevers can be regnant simultaneous with dysentery; the specific rheumatic symptoms precede dysentery, are in part associated with it, or rheumatic pains commence when dysentery ceases, which is why milder asthenic dysentery is so frequently called such, or dysentery itself even called “intestinal rheumatism.” As a rule, the symptoms of localized affliction and fever are not particularly vehement, though they can transition to the more severe forms.
1041. Bilious dysentery. Earlier physicians assumed the presence of this variety when the so-called gastric indicators were already present even before dysentery, or appeared over the course of the illness. They assumed that it arose primarily after bilious fevers, and transitioned into such, and deduced the bilious character of dysentery from the so-called gastric indicators. But such are more or less discernible in every case of dysentery. What was called bilious dysentery is asthenic dysentery with a pronounced affliction of the biliary tract. The fever is not particularly vehement, and noticeably recedes. —
1042. The higher degrees of asthenic dysentery appear under the name of nervous, putrid, and malignant dysentery.
The general affliction then exhibits all the symptoms of the so-called nervous and putrid fevers, which then frequently develop with extreme rapidity into the most severe form and become fatal, in which case one almost always referred to such dysentery as malignant; the lesser degrees of asthenic dysentery, however, can also transition into this type. A diagnosis is based on the indicators of nervous and putrid fevers, whereby the rapid decline of strength, the weak, quick, uneven pulse, trembling of the limbs, muscle twitching, delirious speech, etc. are characteristic.
The indicators of the local affliction usually attain the highest degree. Incessant abdominal pain, horrific urge to evacuate the bowels, ischuria [urinary blockage], fainting, sanious [thin, fetid, greenish fluid consisting of serum and pus] evacuations with a cadaverous odor, cankerous places in the throat, petechiae [reddish or purplish spots containing blood] and skin rashes generally appear, and not infrequently death occurs as early as the fourteenth or fifteenth day.
Occasionally, however, there is absolutely no pain, the ill person lies in a dull soporific stupor, with delirious speech, etc., whereby, however, the urge to evacuate and frequent evacuations still take place. The devastating epidemics of malignant dysentery are of such a nature. Occasionally one also finds asthenic dysenteries associated with malignant intermittent fevers.
How Dysentery Terminates
1043. The course and duration of dysentery, like its termination, are quite varied. Terminations include:
(a) Complete restoration of health. Milder forms transition to health within five to seven days, the more severe forms after two or three weeks or even longer.
(b) Aftereffects . The most frequent aftereffect is an affliction of the intestinal tract. Indications very frequently include sensitivity or irritability of the tract, urge to evacuate, hemorrhoidal complaints, chronic diarrhea that is often quite stubborn with an elimination of mucous and pussy substances, localized problems with the intestinal tract, particularly of the rectum. Such aftereffects also include blockages because of a thickening of the intestines, suppuration, disorganization of other parts. — Finally, dropsy and consumptive fever also often occur; jaundice has also occasionally been seen.
(c) Death comes about when the general life activity is extinguished, or through mortification that affects the intestinal tract and especially the rectum. Although abdominal pain and the urge to evacuate the bowels then cease, meteorism [an accumulation of excess gas in the gastrointestinal tract], suffocation, urge to hiccup, chills in the extremities, cold and stinking sweats, anxiety, fainting, hoarseness, speechlessness, Hippocratic face [a pinched expression of the face, with sunken eyes, concavity of cheeks and temples, relaxed lips, and leaden complexion] — all portend the imminence of death.
1044. [Caelius] Aurelianus called dysentery rheumatismum intestinorum cum ulcere. More recent physicians, seeking to explain the nature of the localized affliction, have drawn parallels between dysentery and other illnesses, viewing it as a catarrh of the intestine or as a blennorrhea [mucous discharge, esp. from the urethra or vagina], and it is undeniable that these illnesses not infrequently do quite resemble dysentery, though very frequently there is much more going on than merely catarrh. Others call it a condition of increased irritation of the intestines, especially of the large intestine.
Our opinion, however, is that such designation conforms only to hypersthenic dysentery, which is by far less common. Still others have explained it as an inflammation of the large intestine, though such is not really present in the majority of cases. The elder Frank compares some kinds of throat inflammation and dysentery, specifically throat inflammation of the skin or that ulcerates, and so-called malignant dysentery, both of which are distinguished by analogous symptoms and the maladies that generate them. [William] Cullen locates the most immediate cause of dysentery in the spasmodic contraction of the transverse colon, with which [Ernst] Horn concurs in assuming the presence of a spasmodic affliction of the intestines.
1045. The concurrence of all these comparisons as applied to certain degrees and types of dysentery, as well as the inadequate nature of the explanations for any attempt to subsume dysentery in general among these various forms of illness, demonstrate most clearly that we have not yet arrived at any clear understanding of the true nature of dysentery. — It seems as if by oversimplifying this illness, we have missed our goal.
Every case of dysentery, even the mildest, is accompanied by two symptoms, namely, blennorhea affecting individual parts of or the entire intestinal canal, and increased peristaltic activity in the lower part. Hence the mildest form of dysentery resembles a catarrh of the intestine, and thus also a mucous diarrhea. In the latter cases, however, excrement is still being evacuated, since the abnormal function has not yet sufficiently increased for fecal matter to be held back in the upper intestine.
The increased vehemence of this illness, however, brings about spasmodic concretions in the upper intestine and, by contrast, increased peristaltic activity in the lower that constantly increases as it moves toward the anus, whence the withholding of intestinal feces, the frequent evacuations of liquids, the urge, and tenesmus. In the higher degrees of the illness, an inflammation of the intestine occurs that is sometimes milder and more superficial, yet sometimes can also become more profound and extremely violent, in which case it then causes the highest degree of mortification.
The disposition of the evacuations parallels the violence and disposition of the illness itself. In the beginning: simple blennorhea; after increasing vehemence: multiple intestinal exhalation, blood secretion; and with incipient inflammation the products of the excreted lymph become admixed and are then gradually increasingly altered, until finally, in the highest degree of colliquative evacuations, paralysis of the vascular system occurs.
1046. Fever cannot be viewed as an absolutely necessary component of dysentery. The mildest degrees of dysentery can completely lack fever. That fevers must indeed be present in the most frequent cases results from the vehemence of the localized affliction of an organ as important as the intestinal canal, though in part also from its origin in epidemic noxiousness, through which the entire organism is afflicted, notwithstanding the intestinal tract most noticeably. This explains why fever does not so often arise consensually after dysentery has already begun, but rather simultaneously with it, or is present even earlier. The same applies to epidemically regnant pneumonia, throat inflammations, etc.
1047. There is no particular disposition for dysentery. In the case of epidemic dysentery, subjects of every age and sex are afflicted. Only to the extent that all external potences exert a stronger effect in the case of diminished vital activity can one say that asthenicized subjects with weakened intestinal canals are more easily afflicted.
Contributing noxiousness includes first and foremost an epidemic disposition of the air. Damp cold following great heat is certainly a primary factor, as demonstrated by autumnal dysentery, dysentery in hot climes or through chills in the cool night air after great heat during the day. Yet these alone can likely not suffice as explanations, since even amid weather conditions favoring dysentery, it nonetheless does not always occur.
1048. Chills and repressed skin transpiration have also been adduced as causes of dysentery. Although one cannot deny that such are often present and contribute, how often does dysentery, or even diarrhea, fail to appear even following chills? — Consumption of fruit was earlier adduced too universally as having caused dysentery. In cases of hyperasthenic dysentery, moderate consumption of ripe, acidic fruit can serve as a remedy; unripe, acerbic, watery, flatulent fruit, as well as fruit tainted by mildew and honeydew, consumed in large quantities, can indeed contribute to causing dysentery. Recent experience has shown that swampy air, which has been viewed as a primary cause of dysentery, seems to contribute less to causing dysentery than it does other forms of asthenic illnesses.
1049. Dysentery has been viewed as indisputably contagious, and a unique contagion declared to be the cause — an opinion, however, deriving quite incorrectly from the epidemic distribution of the illness. I and many other physicians have exposed ourselves to infection without ever becoming infected, and Richter, Horn, and I myself and many others have never seen a persuasive example of contagious infection. One can, however, acknowledge the possibility of qualified contagious infection when the dysentery itself is the symptom of contagious typhus. Opponents generally ascribe its contagious power to the transpiration associated with excrement. — The hypothesis of the origin of dysentery through bilious causticity no longer requires refutation.
1050. The prognosis for dysentery is in general not at all as bad as it is often made out to be. The specific prognosis depends largely on the character of the fever, whereby the various symptoms accompanying the fever are to be considered. The vehemence of the localized illness usually corresponds to that of the fever and is discerned from the increase and decrease of symptoms.
As long as excrement is being evacuated, the illness is yet mild; the more frequent the evacuations, the more vehement the urge to defecate, the more enduring the pain, the more abnormal the evacuations become, all the worse is the illness becoming. The signs of inflammation and mortification have been mentioned above. — It is of no great consequence whether the excrement is bloody or merely mucous (red and white dysentery). Significant bleeding is used in cases of hypersthenic dysentery.
A false diagnosis and incorrect treatment of hypersthenic dysentery can occasion mortification and death even in this otherwise harmless form. In the case of the higher degrees of asthenic dysentery, the prognosis is determined according to the same rules supplied for typhus.
Translation © 2014 Doug Stott