and having numerous crystalline-like particles suspended in it. At other times, the gall-bladder is full of a dark green, thick, and very viscid bile -so stringy, that it may be drawn out in filaments three or four feet in length.

With respect to the gastro-enteric membrane, it is declared to be, in most cases of Dysentery, "healthy; in all cases of simple dysentery the alterations in the canal are circumscribed by the ilio-colic valve. In scorbutic dysentery the ilium is affected, as is mentioned under the head of that complication. Gastro-enteritis is at certain times an accompaniment of dysentery, and is a dangerous complication, on account of the obstinate exhausting vomiting which may attend it. There are various shades of vivid, dark, or hæmorrhagic redness in small intestines, particularly ilium; enlargement and occasional ulceration in a small degree of Peyer's and of the solitary glands, most usually of the latter.""

Dr. Parkes says that, in dysentery, the urine in general very rapidly decomposes, and acquires an ammoniacal smell. As we have already alluded to the relation between Dysentery and Hepatitis, it is unnecessary to say more upon the subject now. Our author agrees with Annesley and other writers of note in admitting that the two diseases may stand, the one to the other, either as cause or effect; for there is one form of " dysentery supervening to disease of the liver," and there is another, "when the affection of the liver supervenes to dysentery." It is often exceedingly difficult to determine which is the primary, and which is the secondary, affection. Some writers have been too much in the habit of asserting that Dysentery is generally, or at least often, caused by a vitiated and acrid state of the bile. Dr. Parkes objects to this doctrine for the following very satisfactory reasons:—

"First.-Because, when this deranged secretion does occur, we have bilious diarrhea, and not true dysentery.

"Second.-Because there is often no irritation of the mucous membrane of the small intestines, to which we should suppose the so-called irritating hepatic secretion to be at least as hurtful.

"Third.—Because, under this supposition, the dysentery should be present during the whole course of the disease, and in every case.

"Fourth. Because dysentery, in like manner, complicates some diseases of the spleen which pour out no irritating secretion.

"Fifth.—Moreover, the secretion has not been proved by chemical analysis, or any other test, to be possessed of irritating qualities; its irritating properties have been supposed, and the supposition has been received as if it were an established fact.

"Sixth.-In some cases, in which the secretion really does appear to be irritating, viz. by producing excoriations round the anus, and scalding the patient when he goes to stool, the mucous membrane of the colon, previously ulcerated in antecedent dysentery has been found by me to be healing rapidly.

"I have not mentioned the adynamic variety, because this is almost always a case complicated with remittent fever or with typhus. As I have observed in a subsequent section, among the dark races the ulcers are atonic, and may require stimulants; but by the term 'adynamic dysentery' is meant more than this, viz., a failure of the powers of life with dysentery superadded. I have never seen this apart from fever or cholera."

1846.]

THE SCORBUTIC FORM OF DYSENTERY.

379

"So far from irritating secretion producing the consecutive dysentery, I have been led to think that the absence of all secretion has been the cause of this disease; in other words, when hepatitis has terminated in partial suppuration, and bile is still secreted, although altered in appearance, then there is no dysentery; whereas, when from extent or peculiar situation of abscess no bile is secreted, dysentery appears to supervene. This opinion is founded on a few observations only, and I mention it here simply that its correctness may be tested by the observations of others."-P. 59.

The reader will probably perceive in these remarks a certain coincidence with the views so earnestly insisted upon by Dr. Macgregor, in his late work on the diseases of the North-Western Provinces of India-vide the number of this Journal for last April.

Besides Hepatic Disease, Dysentery is often associated with Remittent or Intermittent Fever. We have so recently dwelt upon this point, in our description of the prevailing diseases among our soldiers and sailors in China, that it is not necessary to do more than merely to refer to it. We pass on to a brief notice of

Scorbutic Dysentery. This is a most serious and unmanageable form of the disease. It proved very fatal to our troops at Rangoon in 1824; and is always apt to occur on board transports and other vessels, when the ventilation and food are faulty. Every now and then, it will be found in some soldiers at particular stations, although the rest of the men remain quite exempt. Probably, much depends upon the original vigour and strength of constitution, as well as upon the condition of the general health of the patient for some time previous to the attack.

"A soldier will often have a certain amount of scurvy for a short time, for which he never thinks of coming into the hospital; he is annoyed with various symptoms of dyspepsia, with rheumatic pains in the legs, perhaps with an occasional eruption in the same parts of a few purpuric spots or slight ecchymoses; the rheumatic pains are chiefly in the calves, hams, or ankles, and sometimes there is burning of the feet; there is occasional bleeding from the gums, and when these are examined they are found to be slightly swollen and of a dark red colour. The whole amount of the disease, however, is trifling, and a man will generally do his duty, and gradually recover without medical aid. If, however, from any cause an attack of remittent fever or of dysentery supervenes, then this constitutional taint at once appears in the way in which it modifies the course of these complaints.”—P. 123.

In the Scorbutic form of Dysentery, the ilium is much more frequently the seat of ulceration and hæmorrhage from the bowels, and perforations of their coats are of more frequent occurrence, than in the ordinary form of the disease. It deserves to be particularly noticed that the mouth is always very readily affected with mercury, whenever there is any tendency to the scorbutic diathesis.

Treatment of Dysentery.-Is Mr. Parkes warranted in asserting that, "in the treatment of common acute dysentery, we have an infallible guide in the appearance of the evacuations? Many other symptoms, as general pyrexia, tenderness of abdomen, heat in course of colon, tormina and tenesmus, when present, are valuable as accessory phenomena; but the ab

sence of any or all of these is never an indication, when the stools point out an opposite course of treatment."

We much doubt whether any judicious practitioner would determine his line of treatment from the characters of the stools alone, irrespective of other symptoms; and indeed Mr. Parkes, in the very next sentence after that now quoted, admits the importance of such aid in a therapeutic point of view: for he says:—

"As long as the stools are numerous (the attack being recent and uncomplicated), bloody, sanious, dark, and copious or scanty, lymphy, shreddy, or like meat-washings; or a mixture of blood and slime with or without partial fæculence or nearly pure blood, florid, or dark, mixed with a peculiar red mucus; or fæculent, yellow, copious liquid, and stained with blood; and more particularly when with these symptoms there is pain on pressure, and great tenderness, as is the case in most instances, or heat in course of colon, depletion must be actively employed."-P. 140.

In the early stage of the disease, our author strongly recommends, after venesection has been employed, the repeated and free application of leeches over the cæcum and sigmoid flexure-"three times in 24 hours, till the stools become fæculent." This practice may require to be persevered in for three or four days; after which, the daily number of leeches may generally be lessened. If there be much tenesmus, leeches to the anus give great relief. After bleeding, general and local, mild oleaginous purgatives are the most useful remedies in the early stage of dysentery.* Opium, alone or in conjunction with calomel (3-5 grains), or with blue-pill and ipecac., will generally require to be administered at the same time. Dr. Parkes is not friendly, upon the whole, to the exhibition of large doses of calomel with the view of rapidly affecting the system. That the practice often succeeds, he does not deny; but then it is to be remembered that— not to mention its very frequent failure-the subsequent effects upon the health of the patient are often injurious. It is invariably contra-indicated in the adynamic and the scorbutic forms of the disease; nor should its use ever be continued when there is reason to believe that hepatic suppuration has ensued. The therapeutic action of this potent drug appears mainly to consist in relieving congestion of the capillaries, and in causing absorption of effused lymph. Hence, in our author's opinion, "the real indication for salivation is the effusion of lymph; and consequently in chronic dysentery, and in the after stages of very severe acute dysentery, in which convalescence is so protracted as to approach chronic dysentery, ptyalism slowly produced, and carried to the point of a very gentle action on the mouth, is invaluable."+

*Sulphur, given in drachm doses at bed-time, has been found by Twining and other practitioners to suit better, in some cases of chronic Dysentery, than any other aperient.

*

*

"The preparation," says Dr. P., "which I have found most useful, is the Bichloride of Mercury-commencing with doses of one-eighth to one-sixth of a grain-in combination with the preparation of cinchona. * The blue-pill, or small doses of calomel, with ipecacuan., gentian and taraxacum may be substituted. Blisters, and frictions over the abdomen with a mixture of Iodine and mercurial ointment, are to be used according to circumstances."

1846.]

TREATMENT OF DYSENTERY.

And subsequently he remarks :

381

"For my own part I have ceased to use mercury in dysentery, in any other way than as an alterative, except in chronic and long protracted and recurrent acute cases. I never aim at ptyalism, and can confidently assert that my recoveries have been greater in number, and more complete, since I in a great measure abandoned the use of mercury, than when I gave it in large quantities." P. 145.

*

Dr. Parkes does not seem to have used Emetics (we need scarcely say of Ipecacuan), in the early stage of acute dysentery; although they are certainly among the safest and most effectual of all remedies. He reports favourably of the nitric and nitro-muriatic acids in mild cases." "Injections of opium, ipecacuanha, acetate of lead, cold water, suppositories of opium and ipecacuanha, give great relief to the tenesmus. Injections of the acetate of lead in large doses, such as one drachm every four hours, are sometimes very useful.

"The warm bath relieves tenesmus, and the irritability of the bladder, which so commonly produces frequent painful and difficult micturition. Cold water injections sometimes relieve this also."-P. 147.

In the adynamic form of Dysentery, Mr. P. says that "alum combined with catechu and camphor is the best treatment, with small and frequentlyrepeated doses of Dover's powder between each dose of alum. Injections of alum are very useful in that variety where the intestine is so disorganised as to tear like wet paper after death." In the scorbutic variety, the results of treatment are often most unsatisfactory. All depletory means must be avoided altogether, or only used with the greatest circumspection. We much doubt whether mercury in any form should be administered: Dr. Parkes advises small doses of pil. hydr. ipecacuan and nitric acid, opium in enemata, a farinaceous diet with vegetables and lemonade.†

* In a recent number, we suggested to East India practitioners to ascertain the state, whether it be alkaline or acid, of the alvine evacuations in such a disease as dysentery. It seems not improbable that we might thus obtain a guide, in certain cases at least, for the selection of some of our remedies.

The following practical remarks of Dr. Fergusson (in his "Notes and Recollections," reviewed in our last number) on the allowance of fruits and vegetables in acute Dysentery deserve notice, as a contrary opinion too generally prevails.

"Because the acid and subacid fruits sometimes occasion griping when in health, these, and vegetables of every kind, are strictly prohibited. They are, however, amongst the best remedies. Nearly a hundred years ago, Sir John Pringle, one of the best physicians our armies ever possessed, proclaimed that ripe grapes were a cure for dysentery. The Portuguese and Spanish physicians, when I was in the Peninsula, went farther, and to ripe subacid fruits of every kind, added lemon-juice, with the best effects. Our own faculty, in different parts of the world, have highly lauded the mineral acids, more especially the nitric, and, in an epidemic dysentery which not very long ago afflicted Ireland, after one of our best summers, cream of tartar in large doses was found to be nearly as beneficial as mercury; in short, the acids, in every shape, but more especially in that of ripe fruits, will be found excellent remedies by all who can overcome their prejudices so far as to give them a fair trial."

66

*

*

*

*

I believe, therefore, that the free, but not immoderate, use of fruits, by assistNo. 106. 26

Whenever there is any reason to believe that Dysentery is at all complicated with co-existing Remittent Fever, we must never forget to combine quinine with our anti-dysenteric remedies. In closing these remarks on the treatment of Dysentery, it may not be amiss to remind the young practitioner that the same line of practice is not suitable in all seasons, or to all individuals alike. One year, the disease will bear depletion much better than another; and what may suit the robust and well-nourished European will be all but life-destroying to the feeble vegetable-feeding Hindoo.

RHEUMATISM.

This term is applied by Dr. Geddes to those cases, "in which pain in periosteal, ligamentous, or muscular structure, has formed the chief symptom of disease; attended generally, in the two first, with swelling and other symptoms of inflammation." During the five years from 1828 to 1833, there were between 570 and 580 admissions into the hospital from this disease. One season of the year does not seem to have been more favourable for its development than another. On the whole, fewer cases occurred during the cold than during the hot months. Out of 160 patients, the muscles and ligaments were the parts chiefly affected in 47; these structures along with the periosteum in 43; the muscles only in 23, and the ligaments only in 28; in 5, the disease was confined to the periosteum; in 8, this structure was affected along with the joints, and in 3 with that of the muscles. As might be expected, the amount of complication was usually much greater in the relapse, than in the primary, cases. The rheumatic affection was not unfrequently associated with Neuralgia in some part or another. One-half of the cases appear to have been attended with febrile re-action. This was however seldom very severe. In onehalf of the febrile cases, the fever was regularly or irregularly paroxysmal -either remittent or intermittent. The number of cases of relapse was very considerable. In two-thirds of the cases, the duration of treatment was from 4 to 20 days; in the remaining third, it extended from 20 to 60 days and upwards. With respect to the causes, predisposing and exciting, of the disease, the operation of previous Syphilis appears to have been the most frequent; and this, whether mercury had been used for its cure or not. The general results of our author's observations on this head are, "that from constitutional peculiarities, the syphilitic virus gives a tendency to the occurrence of Rheumatic Inflammation; and it is probable that this disposition is increased by the exhibition of mercury, when the effects of this medicine are not so severe as to induce the patient to avoid

ing to keep the bowels soluble, is at all times a preservative against dysentery; and that, when the disease is present, the same use is not only harmless, but, as in the case of the dysentery in Trinidad, may furnish a most important remedy towards a cure. For, if we examine the dismal records of this scourge to our fleets and armies, we shall find that its worst ravages have been seen amongst the famished garrisons of besieged towns, or in ships remote from land, while navigating the tropical seas, or in barren encampments, where fruits could not be found."