/-v w THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID H -> t TROPICAL DYSENTERY MD CHRONIC DIARRHOEA LIVER ABSCESS — MALARIAL CACHEXIA — INSOLATION WITH OTHER FORMS OF TROPICAL DISEASE HEALTH OF EUROPEAN CHILDREN AND OTHERS IN INDIA SiK JOSEPH FAYREE, K.C.S.I., LL.D, M.D., F.R.S. PRESIDENT OF THE MEDICAL BOARD, INDIA OFFICE, HONORARY PHYSICIAN TO THE QUEEN AND TO THE PRINCE OF WALES, ETC. ETC. ETC. LONDON J. & A. CHURCHILL, NEW BURLINGTON STREET 1S81 TO SIE WILLIAM MUIE MTJIE, K.C.B., M.D. HONOEAEY PHYSICIAil TO THE QUEEN DIEECTOE-GENEEAIi AEMY SCEDICAL DEPAETMENT THIS VOLUME ON TROPICAL DISEASE Is SebUateb IN TOKEN OF THE AUTHOR'' S SINCERE REGARD ANB ESTEEM iViS5n971 PEEFACE. This volume consists of Lectures and Papers that have, from time to time, been read, or have appeared in the medical journals. Those on Tropical Dysentery and Chronic Diarrhoea were the Lettsomian Lectures of 1881, and are published in accordance with a desire expressed by the members of the Medical Society of London, before whom they were delivered. The subjects are treated clinically. The descriptions of Dysentery, Diarrhoea, Liver Abscess, and Cachexia will, I hope, be useful at home as well as abroad, for the chronic forms and sequelae of these diseases are frequently met with in England. I desire to record my sincere thanks to all who have assisted me to prepare these Papers. London, July, 18S1. CONTENTS, VAGE TROPICAL DYSENTERY AND CHRONIC DIARRHCEA. Lecttjee I. — Dysentery: Histoeicax Retrospect — Geograph- ical Distribution in Indian and other Foreign Stations — Etiology— Symptomatology .... 1 Lecture II. — Dysentery {continued) : Pathology and Morbid Anatomy — Treatjient of Acute Dysentery — Cases — Dysentery with Liver Abscess and Cases A^^TH other Complications 46 Lecture III. — Chronic Dysentery: Pathology — Treatment — Tropical Diarrhcea — Symptomatology — Morbid Ana- tomy—Treatment — Cases of Chronic "Dysentery and Diarrhoea 118 II. ON THE BAEL FRUIT AND ITS MEDICINAL PROPER- TIES AND USES 172 IIL LIVER ABSCESS. Single and Multiple— Question of Relation to Dysentery — Etiology — Pathology — Symptoms — Treatment — Punc- ture UNDER Antiseptic Precautions — Cases . . . 192 X CONTENTS. IV. PAGE ON THE MALARIAL SPLENIC CACHEXIA OF TROPICAL CLIMATES. Etiology — SrirPTOJiATOLOGY — Pathology — Teeatment . . 221 V. ACUTE MALARIAL (EDEMA : BERI-BERI. Etiology— Pathology — Symptomatology — Morbid Anatomy — Treatment 231 VL BRONCHOCELE. Etiology — Symptomatology — Geographical Distribution — Treatment 248 VIL ELEPHANTIASIS ARABUM. Etiology — Symptomatology — Morbid Anatomy — Relation to Filaria Sanguinis Hominis — Treatment .... 258 VIIL ON THE RELATION OF FILARIA SANGUINIS HOMINIS TO THE ENDEMIC DISEASES OF INDIA . . .275 IX. SUNSTROKE. Varieties — Symptomatology — Pathology — Treatment — Sequels — Cases 294 CONTENTS. XI X. PAGE DENGUE. Etiology — GEOGRAPniCAL Distribution — Symptomatologt — Treatment 314 XL ON THE HEALTH OF EUROPEAN CHILDREN IN BENGAL 322 XIL ON PRESERVATION OF HEALTH IN INDIA. Lecture to the Students of the Royal Engineering College, Cooper's Hill 347 XIIL ON THE RAINFALL IN INDIA. Relation to Climate and Influence on Health and Disease . 382 TROPICAL DYSENTERY AND DIARRHCEA. LECTURE I. Mr. President aiv^d Gentlemen, Wlien tlie Council of this Society did me the honom* of inviting me to deliver the Lettsomian Lectures this year, I hesitated to undertake the duty, as I did not feel assured that I possessed sufficient special knowledge of any subject to justify me in appearing as a lectm-er before an audience of such large and varied experience as that of the Medical Society of London ; but, on reflection, it seemed to me that I might, without presumption, fulfil the object of the founder of these lectures, and at the same time turn the experience ' gained during my service in India to account, by submitting some practical observations on certain forms of disease whicli, whilst common in that and other tropical and sub-tropical countries, are not unknown here in their chronic forms ; and this seemed the more appropriate, because the sequelae of the diseases I propose to describe are to be observed in oiu- own coimtry as well as in the tropics, in the case, chiefly, of persons who, returning from India, China, or the Colonies, are gradually becoming more numerous, and consequently more interesting to medical men at home. The subjects, therefore, that I have selected are dysentery and diaiThoea, as observed in their acute and chronic con- ditions in India and the tropics, and in their chronic stages, and consequent visceral lesions, which are met ■with at home, B Z TKOl'UAI. DYSEXTKHV AND 1)1 ARKira-;A. and are frequently the cause of serious deterioration of health, protracted suffering, and occasionally of death ; the treatment and management also being often tedious and difficult — an assertion that I believe will be borne out by medical men who have been brought in contact with a class of cases which may now be met with in almost every part of the United Kingdom and at continental health-resorts ; for, almost dail}', invalids are returning to Europe in quest of recovery from this or some other form or sequel of climatic disease. The influence of change of climate on the progress and termination of these comj)laints is a subject of consider- able interest, and well vt'orthy of consideration ; for our rapidly extending relations with India, China, Africa, and other foreign countries, and the consequent increased inter- communication, facilitated by imj^roved means and channels of intercourse, are causing closer approximation of interests, and are bringing home to us also in this country the im- portance of the part played by climate in regard to its effects on the health of Europeans, not only in respect of their fitness to encounter its influences, but as regards the proba- bilities of future health for those who are compelled, in the course of duty or business, to return to the country in which they have abeady suffered. From this point of view I think the subject may be of interest to the members of this Society, whose indulgence I ask whilst I endeaA'oiu' to lay' before them some observations, which, being the outcome of personal experience, will not, I triist, be devoid of in- terest. In the course of my remarks I shall have to speak of much that relates in common to dj'sentery and diarrhoea ; but that which is peculiar to each will be considered and described separately as I proceed. HisTORicAi, Retrospect. In the ancient system of Hindoo medicine of the Ayur- veda and the commentaries of Dhanwantari, Charaka, and LECTURE I. O Sussutra, wkich carry us back nearly 3,000 years, and in later Sanscrit writers, dysentery is described by the name of Atisar, under two forms — Ama-apaka, or acute, and Pak- itsar, or chi'onic ; these again are subdi^■ided into six varie- ties, ascribed by those ancient sages to changes in air, bile, phlegm, food, or to perturbations of the emotions and passions ; whilst the symptoms and treatment are detailed according to their notions of disease. Herodotus refers to it in his writings ; Hippocrates de- scribed it and gave it the name of " Dysenteria," by which it is now known. Thence to the close of the sixteenth century by Grreek, Roman, Arab, and later by nimierous writers down to our o^^^l day, medical literatui'e abounds in descriptions of the disease, some of which, even by the Fathers of Medicine — Areteeus, Celsus, Gralen, Coelius Aurelianus, Alex, de Tralles, and others, — are so precise as to leave little to modern description ; showing, too, that it had even then, according to the know- ledge of the time, been the subject of careful clinical observation and pathological research. My object being a practical exposition of some of its clinical aspects, I shall not attemj^t any detailed historical account of the disease, or do more than indicate some of the most important authorities, especially those who in recent times have added so much to our knowledge of its treatment. Until after Hippocrates, the term dysentery was applied to other diseases accompanied by discharge of blood from the bowels ; but early in our era it began to be restricted to a single disease, which was ascribed to a variety of causes — acid bile, acrid secretions, and so on — whilst bloody stools, mucus, and ulcerated bowels were recognized as its cha- racteristics. The views of the classic writers — Coelius Am-elianus, Archigenes, Aretasus, Galen, and Alex, de Tralles — continued to be held doAvn to the time of Fabricius and Fernel (the modern Galen), in the seventeenth centmy, about which period new opinions began to obtain as to causation and classification, whilst the experience of frequent epidemics gave opportunity for fmiher investigation into the 4 TROPICAL DYSENTERY AND DIARRIKEA. uatiu'e and origin of tlie disease. The writers of the seven- teenth centmy are numerous ; among them Boutins, Boerhaave, Arnold, Chouet, Willis, and Sydenham, who studied it during the London epidemic of 1669-72, and regarded it as intestinal irritation produced by a fever localized in the large intestine, are conspicuous. In the eighteenth century the wiiters are more numerous still, whilst knowledge of the disease was increasing, with more frequent opportimity of stud}dng it. StoU, Pringle, Morgagni, Zimmerman, Degner, Lind, Grilhert Blane, and many others have left faithful descriptions of dysentery in all its forms, and various theories as to its origin. In the present century, and notably dimng the last twent}'- five years, marked progress has been made, especially in the method of treatment. The -^Titers are too nimierous to mention, and I would simply say that to them we are indebted for more accurate knowledge of the pathology and therapeutics of dysentery as a specific disease. Desgenettes, Eollo, Annesley, Baly, Cruveilhier, Bamfield, Parkes, Hu'scli, Bleker, R. Martin, Morehead, Docker, Chevers,. Macpherson, Goodeve, Ewart, Aitken, and Maclean have done much by their teaching or "WTiting to advance our knowledge of the subject. I might, did time permit, cite many others, but these are sufficient to show that a copious literature of dysentery, from the earliest dovra to the latest times, exists. Though now chiefly a disease of tropical and sub-tropical climates, it neither is, nor has been, restricted to such geo- graphical limits. It may appear sporadically any^vhere, and has prevailed wherever men have congregated imder certain unfavourable hygienic conditions of climate, locality, food, drink, and occupation, often in the form of severe and destructive epidemics. Few parts of the world, except the polar regions — and I am not sure that they are an exception — have been exempt fi-om it. Accounts of its ravages in various regions abound in the autliors I have mentioned. LECTURE I. Since the account of it by Herodotus as it affected the Persian army in Thessaly, down to the present day, it continues to be a source of danger and weakness to armies, camps, garrisons, and fleets, and also to the general popula- tion. It was as destructive to om- men at the siege of Harfleiu' and at Agincourt, in 1415, as it was in the Crimea in 1854, or in Afghanistan in 1879. Fernel says that in 1538 it was so general throughout Europe that neither village nor town escaped, notwith- standing that the seasons had been regular. — (Copland's "Dictionary.") The Plague of London of 1665 was followed in the autumn of 1G66 by an epidemic of dysentery, which was infectious, and was considered to have been due to contamination of the air by the plague victims buried in and about London the previous year. — (Copland's " Dictionary.") Other epidemics of it visited London in 1669-72, in 1762, and 1768. No part of Eiu-ope, from Spain to Norway, seems to have escaped. Two hundi-ed years ago it was most prevalent and fatal in London. It prevailed in Ireland in 1722, dm-ing times of scarcity of food, and on subsequent occasions, when it has been a scourge to that island, as in 1846, and always of an adynamic t}^e. France suffered from epidemic dysentery in 1859. Melboiu"ne, in Australia, was ravaged by a severe epidemic in 1853 to 1855. Norway suffered in 1859. It is noticeable that it apparently visits European countries with less severity now than in past times. Two centuries ago it was as great a scourge in England and throughout Europe as it is now anywhere in India; but with the progress of civilization, amelioration of the conditions of living, improvement in agricultiu-e, reclamation of waste and uncultivated lands, better siu'face and subsoil di'ainage, paving of towns, better dwellings and food, and purer diinking- water, it has gradually diminished, or has so nearly disappeared, in this coimtry at least, that few whose experience is confined to our own islands have had the opportunity (beyond an occasional sporadic case) of seeing it either in the acute form, or as an epidemic. How far the extinction of dysentery 6 TROPICAL DYSEXTEKY AND DIARKHUiA. is due to improved hygiene aud ameliorated conditions of living, I cannot say, but it seems as though they stood to each other as cause and effect. Like malarial fevers, with which it has close affinity, it has almost disappeared from our tables of sickness and mortality. Doubtless, were con- ditions like those that developed it in Millbank in 1825, or that recorded by Clouston in 1865 as having occurred in the Cumberland and Westmoreland Asyhmi, in which scorbutic dysentery, due to effluvia from sewage, accompanied by a bad diet, defective in vegetable matter, affected the in- mates, again to occur — a state of things now, we hope, impossible — we should again have similar dire results. But it seems improbable in these days of sanitary reform that such should be the case, or that an epidemic of dysentery should again desolate London like that described by Syden- ham, which proved that our northern latitude is no safe- guard when local insanitary conditions foster and favour the spread of the disease, such as may have been the case even so late as the middle of last centmy, when the death- rate of London from all causes was one in ticenty-four of the population, though even then the public health was improving, and the average duration of human life was slowly increasing. It is now one in forty-fom- or forty- five, and there is no reason, except opposition to, or want of faith in, hygiene, why it should not be much fui'ther reduced. Dysentery has always had peculiar interest for the naval and military medical officers, for it is in theii* special field of operation that it has caused the severest ravages, as the history of om* own and continental military and naval cam- paigns can tell. In Napoleon's Egyptian campaign twice as many men died of dysentery as of plague — i.e., 2,468 of dysentery, 1,689 of plague. Dewar graphically describes the sufferings of the British Army in the same campaign. Desgenettes says it killed more soldiers betAveen 1782 and 1815 than fell in action in the great wars of the empire. The British Army in Holland in 1748 ; the Walcheren campaign of 1809 ; the Peninsular campaign, in the LECTURE I. / Talavera campaigu King-lake says [vol. vi., appendix, page 473, "Invasion of the Crimea"], "The troops in great numbers fell sick, went into hospital, and died from want of necessary succoui' ; from dysentery alone 5,000 men died " ; Napoleon's wars ; the Crimean campaign, where between October 1, 1854, and March 31, 1855 — six months — oiir army had 48,742 cases of sickness,* exclusive of wounds, and of these 18,708 were diarrhoea, 4,441 dysen- tery ; the Franco-G-erman, the Russo-Tm-kish, and the Civil war of 1861 to 1863 in America, when one-foiu-th of all the disease was dysentery or diaiThoea, with a mortality of 12-36 per 1,000 (Clymer), attest the fact that dysentery is one of the greatest difficulties armies have to encounter even in temperate climates, and how much it is attributable to defective food, bad hj'giene, and climatic "sacissitudes ; whilst Indian, Bm-mese, African, and Mexican campaigns declare its severity in tropical climates. Sir R. Martin says, " It is the disease of the famished garrisons of besieged towns, of barren encampments, and of fleets navigating tropical seas, where fruits and vegetables cannot be procured. During the Peninsular, the fii'st Biu'- mese campaign (and I may add the second also), and the late war mth Russia, dysentery was one of the most j)re- valent and fatal diseases which reduced the strength of the armies engaged " ; and I purpose to show you that it proves most destructive in India, its prevalence and fatality there depending apparently on climatic influences and defective hygiene, and that, like fevers, it bears a marked relation to the prevalence of malaria. I have referred to it as a disease of tropical or sub- tropical latitudes, but have abeady said that sporadic cases occur everywhere, while severe epidemics have apj)eared in northern latitudes. As it is endemic and most prevalent in hot countries, and especially in India, I shall confine my remarks mainly to experience derived from that coimtry, and, as the time at my disposal is limited, I shall, after a * This was exclusive of cases treated at Scutaii. Tlic deaths were — dyseutcry G90, diaiTha?a 1,303. 6 TROPICAL DYSENTEllY AND DIARKIICKA. brief reference to its distribution and prevalence in those countries, proceed to consider it in its etiological, clinical, pathological, and therapeutical bearings. Let me, then, ask your attention to its prevalence in those parts of the world where oiu- troops and sailors are serving. The information is gathered from the official reports, and includes also the gaol and some part of the civil population, which, from the circumstances imder which tliey are framed, supply data that may be regarded as reliable. I have said but little as to the incidence or fatality of dysentery in past or even in recent times, though sufficient to direct attention to the universal character and prevalence of the disease. I pro- l^ose, however, to enter a little more into detail in regard to India, as I wish to bring you face to face, as it were, with the complaint as it now occurs in a large portion of our dominions. As regards diarrhcea, I shall include it with dysentery in the statistical returns, and shall conclude what I have to say in the third lecture with some clinical remarks on the pathology and treatment, especially of the chronic form of the disease — to whicli, indeed, my remarks will be chiefly confined — so frequently seen in old residents of tropical climates, and which seems to be so nearly allied to dysentery. Geographical Distribution akd Prevalence in India and other foreign stations. Official retm-ns for 1878 show that in the European Anny of India, with an average monthly strength of 56,475 men, there were in that year 2,784 cases of dysentery and 3,972 of diarrhoea; of the former 98 and of the latter 4 cases proved fatal, or 1-73 and 0-7 per 1,000. The greatest pre- valence (314) occurred in September, the lowest (186) in March. There were 49-3 cases of dysentery and 70*3 of diarrhoea per each 1,000 of strength ; whilst 3-52 of dysentery and -10 of diarrhoea died of each 100 treated; 125 were LECTURE I. 9 invalided for dysentery and 30 for diarrhoea, or 2'75 per 1,000 of strength. Of 5,170 European women connected with the European regiments, there were 164 cases of dysentery, of which 7 were fatal ; and 299 cases of diarrhoea, of which 8 were fatal — 1-35 of dysentery and 1'55 of diarrhoea per 1,000 strength. Of 10,423 European children, there were 289 cases of dysentery and 1,033 of diarrhoea; 40 of the foitaer and 149 of the latter, or 3-84 and 14-30 per 1,000, were fatal. In the Native army of 117,272 men there were 9,622 cases of dysentery and 4,747 of dian^hoea ; 191 of dysentery and 112 of diaiTlioea proved fatal, or 1*63 and •95 per 1,000 respectively ; 82 per 1,000 of strength were admitted for dysentery, and 40*5 for diarrhoea. Of a gaol population of 127,914 persons, chiefly natives, there were admitted 14,487 for dysentery and 12,998 for dian'hoea. Of these 2,326 proved fatal from dysentery, 18G5 from diarrhoea — being a fatality from both combined of 32-76 per 1,000, or of 15-25 of each 100 treated. Comparative statements show the relative prevalence and mortahty of the diseases in different parts of India, and that dysentery is more severe in Madras than in the other Presi- dencies. I have taken these details both from the European and Native retm-ns, to show the extent of its prevalence among the native popidation, the seasonal prevalence, as well as a comparison mth fever. The extent of seasonal variation of prevalence in the hill- stations is noted, and it will be seen that, although less severe, the disease occui'S at those elevations of from 4,000 to 8,000 feet above the sea-level. It must be remembered, how- ever, that the seeds of the disease may have been canied up from the plains. 10 TKUl'ICAJ. DYSKMERY .VM) 1)1 A KltlUKA. COMPARATIVE STATEMENT OF THE RATIOS OF SICKNESS AND MORTALITY IN THE EUROPEAN ARMIES OF THE THREE PRESIDENCIES FOR THE YEAR 1878. Ratio per 1,000 of strengtli . For the year. Army of Army of Army of Army of Bengal. Madras. Bombay. India. Admission-rate : 1 1 Dysentery 39-7 i 93-9 35-3 49-3 Diarrhoea 68-6 1 72-3 74-3 70-3 Death-rate : ! Dysentei-y . . . . l-ol 3-05 1-12 1-73 Diarrhcea 0-03 0-19 0-10 0-07 Mortality per 100 cases treated. Dysentery 3-80 3-25 3-14 3-52 COMPARATIVE STATEMENT OF THE RATIOS OF SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS IN THE PROVINCES OF THE BENGAL PRESIDENCY DURING THE YEAR 1878. Ratio per 1,000 oi strength. For the year. C ft (D p Gangetic Provinces. Rohilcuud and Meerut. Agra and Central India. Punjaub. Army of Bengal. Admission-rate : Dysentery 29-0 37-9 37-9 37-0 39-1 28-9 39-7 Diarrhoea 33-7 82-5 74-2 65-2 58-3 60-4 68-6 Death-rate : Dysentery 1-05 1-40 0-27 1-93 2-28 0-45 1-51 Diarrhoea 0-10 0-08 Mortality per 100 treated: Dysenteiy 3-34 3-68 0-71 5-13 5-84 1"55 3-80 COMPARATIVE STATEMENT OF THE RATIOS OF SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERV- ING IN THE PROVINCES OF BOMBAY AND MADRAS DURING THE YEAR 1878. Ratio per 1,000 of strength. For the year. Rajpootana, Mahva, Scinde, Aden. ^ o a 58 O ^ CD a ° a Army of India. Admission-rate : D3^sentery 40-4 78-5 59-2 96-7 93-9 35-3 49-3 Diarrhoea 85-0 84-4 40-2 86-8 72-3 74-3 70-3 Death-rate : Dysentery 1-43 2-11 j 1-09 4-16 3-05 1 12 1-73 Diarrhoea 0-14 0-22: .. 0-19 0-10 007 Mortality per 100 treated : 1 Dysentery 3-54 2-69 1-84 4-30 1 i 3-25 3-14 3 -.52 LECTURE I. 11 SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERVING IN BURMAH AND PEGU DURING THE YEAR 1878. Causes Admissions into hospital in each month. Total admitted during the yeai*. Admitted per 1,000 of strength. O T3 of admission. >-5 i 1 < ^ S 1-5 >> "3 ►-5 1" < p. 03 o > o d Q °^2 to o s s Dysentery Diarrhoea 21 20 18 15 15 8 13 20 17 14 25 25 1219 1 8 11 10 14 5 14 12 9 17 11 186 167 96-7 86-8 4-30 SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERVING IN THE PUNJAUB DURING THE YEAR 1878. Admissions into hospital in each moutli. s "^ 3 « 1 Admitted per 1,000 of strength. o -d of admission. 1-5 f^ .a o 03 1^ J 00 - 1 o ^2; 6 Died ea( 100 tre Dysentery Diarrhoea 1810 50 44 8 40 37 82 26 50 18 48 18 17 49 55 42 38 89 82 6642 1 46 50 411 614 39-1 58-3 5-84 0-16 SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERVING IN BENGAL PROPER DURING THE YEAR 1878. Admissions into hospital in each month. Total admitted during the year. Admitted per 1,000 of strength. ° » s.a« O O OJ of admission. 1^1 i < 1^ a a 1-5 1 2 "3 ^^ 7 5 s 6 9 p. 00 o O Dysentery Dian-hoea 4 8 5 3 3 5 4 4 2 2 3 4 10 6 4 10 6 55 64 290 33-7 3-64 SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERVING IN THE DECCAN AND IN NAGPORE DURING THE YEAR 1878. Causes of admission. Dysentery Diarrhcea ■ Admissions into hospital in each month. 49 ^ 37 36 31 36!42;34 39 2835 37'25 io,^ 68 81J784632 112103 65.52 22 Q H 37i 558 33' 600 u i p. J3 •3 "3) "S 0, i 2-69 017 12 TROPICAL J)VSE^^TEKY ,\X1) DlAliltiKK.V. SICKNESS AND MORTALITY AMONG THE EUROPEAN TROOPS SERVING IN SOUTHERN INDIA DURING THE YEAR 1878. Causes of admission. Admissions int(j hospital in each month. Total admitted during the year. -< out of ch eated. 1-5 >^ a <; May. .Tune. .Tuly. a o > o p Q S Dysentery- Diarrhoea 29 25 1 2117 1 13 27 23 21 IQlo'sQ 12 1121 1 1 36 16 27 13 19 8 12 4 15 14 272 185 59-2 40-2 1-84 0-54 SICKNESS AND MORTALITY AMONG EUROPEAN TROOPS IN THE HILL-STATIONS AND HILL CONVALESCENT DEPOTS OF THE MADRAS AND BOMBAY PRESIDENCIES DURING THE YEAR 1878. Causes Admissions into hospital iu each month. PI o H Admitted per 1,000 of strength. of admission. 3 1-5 a < >> ID a s -; CD o T3 ID -M D o 3 2 Dysentery . . 2 .. 9 5 6 4 6 6 5 1 4 2 49 o9-l 2-04 Diari'hcBa 2 1 4 2 3 4 10 1 1 4 ..2 34 41-0 * • • STATEMENT SHOWING THE RATIO IN WHICH CERTAIN DISEASES HAVE CONTRIBUTED TO MAKE UP THE ADMISSION-RATE IN CERTAIN STATIONS OF INDIA. Admissions per 1,000 average strength. Fevers. Dysentery. Diarrhoea. Stations : Barrackpore 1509-3 158-0 104-0 Dacca . 505-6 124-5 117-0 Shillong and oiitpo.sts . . 780-2 128-5 61-1 Dinaporc . . 457-4 43-6 9-9 Cawnpoi'e (eleven montlis) 435-7 36 5 15-4 Delhi 1354 8 130-6 43-0 Mooltan . . 958-9 51-3 21-6 Rawal Pindi 596-4 69-5 26-9 Central India Force : Auji-ur and outpo.-^ts 421-1 33-8 4-5 Sehore and Indnre 904-3 164-5 47-8 Dclira Ghazi Khun 920-3 71-9 33-0 Quetta (eleven months) 22864 221 6 159 1 In the hill-stations of tlio Bengal Presidency (1878) : Average strength, ■±•470 men ; the average daily number of sick from — LECTURE I, 13 ^ 1-5 ^ S P 3 < 03 O > o P 1 Dysenteiy. 1 3 2 15 21 22 22 13 10 10 7 3 129 Diarrhoea . 3 3 4 29 43 21 43 68 35 4 4 3 260 Being 28-9 per 1,000 strength of dysentery, 60-4 per 1,000 strength of diarrhoea. Died out of each 100 cases treated, 1"55 of dysentery, of diarrhosa; the total deaths having been dysentery 2, diarrhoea 0. Deaths per 1,000 of average strength, dysentery 45, diarrhoea 0. The greatest prevalence of dysentery was in May, June, July (22) ; the least in January, December, February, March (3). Diarrhoea was most prevalent in April, May, July, August, September (68) ; least in January, February, March, November, December (3). In the Indian civil registration the deaths from diarrhoea and dysentery are recorded under one head — " bowel com- plaints." In 1878 the deaths under this head averaged about 2 1 per 1,000 among 182 millions of people. But the diseases prevail to very variable extents in different districts, as may be seen from the following returns for two years : — DEATHS PER 1,000: "BOWEL COMPLAINTS." 1877. 1878. Bengal . . . . .... 0-98 1-08 North -West Provinces and OucUi 1-98 3-87 Pvmjaub 1-01 1-83 Central Provinces . . 2-0 1 3.52 Eerar 4-80 12-6 British Bnrmah 2-34 1-57 Madras 4-50 1-6 Bombay- 3-72 2-54 Assam 1-50 1-50 The Berar rate is always high, and in 1878 led to inquiry. The figures show the rates intensified by famine in Madras and Bombay in 1877 ; next year there is a great falling-off, but the rates increased in 1878 all over the North of India, due apparently to the secondary famine arising from the sale of grain in 1877 to relieve the famine in Madras and Bombay. 14 TKOl'ICAl, DYSKNI'KRV AND 1)1 A IMJIKKA. To show the prevalence among the general population of a large city where it is endemic, I take the following facts from the report of the Health Officer of Calcutta for 1879 :— The population of Calcutta in 1879 was 429,535. 1,516 persons died in the year from bowel complaints. Ratio of deaths per 1,000 of ]3opulation was — fevers ll'l, cholera 2*7, bowel complaints 3"5, small-pox 1*7, injmy "52, all other causes 10 '5. Fever occupies the first, and dysentery and diarrhoea the second place among death-causes. The deaths from most prevalent diseases in 1879 show the place taken by bowel complaints in the returns : — Cholera DiarrhcBa and dysentery Fevers Small-pox . . Other causes Rat«s i^er 1,000 Mean, 1869-72. 1,568 1,639 4,656 274 4,144 12,281 28-5 Fevers, small-pox, and " other causes," are above the average ; cholera and bowel complaints below it. The influence of season on dysentery and diarrhoea is shown as follows : — January February March . April . May . June July . August September October November December Combined. Of these— Non- Asiatic 24 Mixed races 78 Hindoos .. 1,075 Mohammedans 328 Others . , 11 1,510 l.ECTURK I. 15 The cold months (December and Janiiaiy) give the largest, April and September the smallest, number of cases. One hundred children died in Calcutta of bowel com- plaints ; of these there Avere — Non-Asiatic ...... 1 Mixed races ...... 28 Hindoos ...... 52 Mohammedans . . . . .19 100 " The mortality from diarrhoea and dysentery fell short of the average, and stands below the preceding year. These diseases do not present so marked a seasonal fluctuation as other diseases, but the returns indicate depression in the hot weather and rains, and an elevation during the cold weather." The returns of the Medical College Hospital, Calcutta, for 1879, give the following, according to Dr. McLeod : — Of 63 Europeans treated for dysentery, 14 died, or at the rate of 222 per 1,000 treated ; of 72 natives treated, 27 died, or 375 per 1,000. Of 108 Europeans treated for diarrhoea, 8 died, or 74 per 1,000 ; of 44 natives treated, 10 died, or 227 per 1,000. The death-rates in the Greneral European Hospital were of Europeans 65 per 1,000 from dysentery, and 72 from diarrhoea. Dr. Jones, head of the General Eiu'opean Hospital, Calcutta, informs me that in Dysentery. 1873 .. .. Dysentery. Cases. Died. Cases. Died, 1865 .. .. 272 32 145 13 1866 .. .. 281 32 1874 .. .. 118 15 1867 .. .. 234 10 1875 .. .. 170 14 1868 .. .. 243 12 1876 .. .. 218 13 1869 . . . . 260 17 1877 .. .. 370 14 1870 .. .. 173 14 1878 .. .. 245 6 1871 .. .. 138 (i 1879 .. .. 200 13 1872 .. .. 188 8 16 'IROPKAL DYSENTERY AND DIARRHOvX. From which two facts may he ascertained. First, that since the year 18G7 the mortality has greatly diminished ; secondly, that the disease itself has, since 1870, also diminished in fi'equeney. The former seems to be coincident with ipecacuanha-treatment ; the latter with improved hygiene — perhaps better water ! Dr. S. CouU Mackenzie has sent me the following statement regarding dysentery in the large Native Campbell Hospital. This institution is now the hospital of a great medical school, and has increased con- siderably in size and importance of late years : — CAMPBELL HOSPITAL, CALCUTTA. Total ad- Dysenterj'. Death- rate on total admis- sions. Years. into hos- pital, all diseases. Total treated. Cured. Relieved. Dis- charged othen^^se. Died. 1870 .. 3,415 212 138 61 1-78 1871 .. 4,283 311 199 95 2-21 1872 .. 5,212 424 234 , , 157 301 1873 .. 4,870 333 158 115 2-36 1874 .. 7,149 1,122 585 497 6-95 1875 ,. 7,426 952 521 385 5-18 1876 .. 6,279 761 410 321 oil 1877 .. 6,600 1,174 618 473 7-16 1878 .. 10,604 1,827 593 129 313 770 7-26 1879 .. 7,810 987 292 63 114 605 6-46 The sanitary history of Bombay illustrates the incidence of the disease on the Western side of India for 1879. The last census of Bombay in 1872 gives the mixed population of that city 644,405. It has increased since then, but as the amount has not been ascertained, it is necessary to adhere to the last census repoi-t. There were deaths fi"om Fever . . 8,445 = 3-10 per 1,000. Diarrhcea . . 1,095 = 1-70 „ Dj^sentery . . 1,399 = 2-17 Of childi'en under five years there were deaths fi'om — Fever 3,391 DiaiThcea . . . . .415 Dysentery • . . . .330 Cholera . . . . .17 / LEC'TUKE I. 17 Fevers stand far before all other death-causes ; bowel complaints, excluding cholera, steadily afford the second highest figure in the bills of mortality. To show how uncertain is the incidence of cholera, and how variable, as compared with fevers and bowel complaints, I cite the follow- ing from the Bombay Sanitary Report above referred to : TOTAL DEATHS. Years. Dian-htea. Dysentery. Fevers. Cholera. 1S74 .. .. 607 1,041 0,403 19 1 ST.) . . . , 876 l,3h9 5,244 848 1876 .. .. 815 1,164 5,867 374 1877 .. .. 1,644 :i,203 12,832 2,510 lcS78 .. .. 1,2.58 1,829 9,944 1,183 1879 .. .. 1,095 1,399 8,445 324 The fluctuations of bowel complaints and fevers bear relation to the intensifying causes — e.g., the famine effects began to tell in 1876, they culminated in 1877, and began to decline in 1878-79. Although cholera was influenced, it was not so regularly affected as the other diseases by this cause, A few facts respecting the Central Provinces show that there too dysentery and diarrhoea follow a similar course, and how great a curse they continue to be to the population of India. The average annual mortality in the Central Provinces for five years from these diseases was 2*46 per 1,000. In 1878, the year of scarcity, it rose to 3-52 per 1,000, and in 1879, it had fallen to 2-66 per 1,000. Bowel complaints in India are often con- nected with bad and deficient food, and the Sanitary Com- missioner remarks that " the retui-uing health of the people after a season of want is shown by the great decrease of these diseases." Prevalence in other parts of the world is shown by the following facts derived from the records of the Army and Navy Medical Department for the year 1878 : — In China, in an average strength of 1843'3 men, there were 17 cases of dysentery — 1 died, 9 were invalided ; 80 cases of diarrhoea — none died, 3 invalided. In the West Indies, in an average strengtli of 1119'3, c 18 TROI'ICAL DYSKNTERV AM) DIARRHCKA. tliere were 6 eases of dysentery — none died, 1 was invalided ; 53 cases of diarrhoea — all recovered. In West Africa, in an average strength of 542"08 men, there were 14 cases of dysentery, but no deaths; 19 cases of diarrhoea — no deaths. In the Mauritius, in a strength of 416, there were 15 cases of dysentery, but no deaths; 19 of diarrhoea — no deaths. In Ceylon, in an average strength of 1,015 men, there were 33 cases of dysentery — 2 deaths, 3 invalided ; 47 eases of diarrhoea — all recovered. At the Cape, in an average strength of 5447"80, 173 cases of dysentery — 13 deaths, 2 invalided ; diarrhoea, 358 cases — 2 deaths. In Gribraltar, strength 4,702, there were 10 cases of dysentery and 60 of diarrhoea — all recovered. In Malta, strength 6,201, there were 42 cases of dysen- tery — 39 recovered, 3 died ; of diarrhoea there were 268 cases — all recovered. In Cyprus, strength 894, there were 28 cases of dysen- tery — 24 recovered, 4 died ; diarrhoea, 92 cases —all re- covered. In Canada, strength 1,012, there were 120 cases of diseases of the digestive system, and 1 death. The retiu'ns do not specify the nature of the cases. In Bermuda, strength 2,017, there were no cases of dysen- tery. I may here remark that Bermuda occasionally suffers. My fiLrst experience of the disease, in 1843-44, was in these Islands, where there were many cases in the Naval Hospital. There were 135 cases of diarrhoea, all, of which recovered. The Naval Sanitary Repoi't gives the prevalence of dysen- tery and diarrhoea in II.M.'s fleet at home and foreign stations as follows : — Naval, 1878. Home Station. — In a force of 65 ships of war of various sizes, and among the reser^-e of seamen in the Sheerness LECTURE T. 19 Barracks, making a mean force of 19,000 men, 2 died of diaiThoea and 1 was invalided ; the nmnber of cases admitted not stated. Mediterranean. — Force 36 vessels, 8,231 men. There were 14 cases of dysentery — 6 invalided, 1 died at Malta ; there were 636 cases of diarrhoea — no deaths, number invalided not specified. North American and West Indian Stations. — Vessels 14, mean force 2,620 men. There were no fatal cases, 1 man was invalided for dysentery; 116 cases for diarrhoea, but none proved fatal. South-East Coast of American Stations. — Vessels 6, and a detachment of marines at Falkland Island— mean force 590 men. No fatal cases ; number of cases not specified. Pacific Station. — Force 12 vessels, number of men, 1,740 ; 1 case of dysentery, 171 of diarrhoea — no deaths, none invalided. West Coast of Africa and Cape of Good Hope Station. — Vessels 12, mean force 1,5-50. Cases of dysentery and diarrhoea numerous, — this was due to the Kafir campaign ; a division of the Naval Brigade operating in the Transkei was specially affected. These diseases appear to be endemic in this district. Before the war they were common among the Eui'opeans engaged in trade, but the dysentery rarely ran into the chi'onic form which it so frequently assumes in certain tropical localities. None of the cases were fatal ; 2 invalided for dysentery, 1 for diarrhoea. East Indian Station. — Vessels 15, mean force 2,200 men. There were 44 cases of dysentery, 198 of diarrhoea ; 5 men were invahded for dysentery, 1 for diarrhoea ; 2 men died of dysentery, 1 of diarrhoea. A number of severe cases of dysentery occiuTed in H.M.S. London at Zanzibar, " sup- posed to have been o"wing to chilling of the siu'faoe of the body from imprudent exposure during sleep." EiTors of diet may also have contributed to produce it, and one case was certainly the result of surfeit of pineapple ; finally, climatic causes doubtless played a part in the production of the malarious type of the disease. The treatment was in f 2 20 TROPICA], DYSENTERY AND DTARRIICEA. every instance by large doses of ipecacuanha. Tlie East Indian Stations include the East Coast of Africa, the Arabian Grulf, the Bay of Bengal, and islands as well as ports on the coast, Ceylon, Aden, Zanzibar, and the islands of the Indian Ocean. China Station. — Yessels 26, mean force 2,7G0 men ; 3 deaths from dysentery, 5 invalided ; 6 invalided for diarrhoea ; nimiber of cases not specified. Aiistyalian Sfr/fion. — Ye&sels 4, mean force 840 men; 49 cases of dinrrhoea ; none of dysentery ; no deaths, no inva- liding. Irregular Force. — Vessels 62, mean force 6,870, counting 9 ships newly commissioned proceeding to destination, and ships on passage home or on special service, thus repre- senting all stations and places frequented by naval vessels. There were 20 cases of dysentery, 506 of diaiThoea — 1 inva- lided for dysentery, none for diarrhoea ; 1 death from djsen- tery, 1 from diarrhoea. Of the total forces there were : Dysentery — total, 131 cases, or 2'82 per 1,000 ; 20 were invalided, or a ratio of "43 per 1,000; 7 died, or a ratio of "15 per 1,000. Diarrhoea — total, 2,508 cases, ratio 54*05 per 1,000; 11 invalided, equal to -23 per 1,000 ; 4 died, equal to "08 per 1,000. These returns show that Europeans in India, of the class represented by the soldier and his wife, suffer considerably from dysentery and diarrhoea — men rather more than women, no doubt from the greater exposiu'e incidental to the duties of the man ; and children considerably more than adults in respect of diarrhoea, though rather less in numbers, but more in fatalitj', than the adults from dysentery. The mortality from dysenter}^ in them is nearly 14 out of every 100 cases treated, or about two and a half or three times that of M'onien. The same ma}- be said of diarrhoea in the class here referred to. It is to be observed that for the most part the subjects are young or in early middle life, under constant medical supervision, and enjoying the benefit of the improved hygienic supervision under Avhich the soldier LECTUliE I. 21 now lives in India — a position in which he is likely to be brought under treatment at the outset of the disease. So far their condition compares favourably with that of other well-to-do Europeans in civil life in India. But one can hardly say that the soldiers' children are as favourably placed as the children of Europeans in the higher ranks of life in India ; still it is evidence, as far as it goes, that the climate is inimical to the constitution of many European children, and it tends to strengthen the objections to their going to India in infancy, or to their being kept there after five or six years of age. The native soldier also suffers considerably — 82 -per 1,000 of strength being affected by dysentery, 40'8 per 1,000 by diarrhoea, whilst the death-rate is 2'15 in each 100 attacked by both complaints combined, being a mortality rather below that of the Eiu"opean. But when we turn to the Indian gaols we find that the death-rate is 15*25 per cent., or seven times that of the soldier. The explanation is to be sought in the condition under which the prisoners live, though there can be no doubt that this has been much improved of late years ; I refer to it with no purpose of criticizing the con- dition of Indian gaols, but to illustrate the extent to which bowel complaints are influenced by local causes. (Jf the general population I may remark that they suffer according to locality, mode of life, and the peculiar climate of the district. Dysentery and diarrhoea stand next in order to fevers as a cause of mortality ; and experience assures me that the scope of inquiry as to etiology must extend beyond mere local conditions. According to Sir A. TuUoch and Dr. J. Ewart, the pre- valence and mortality of dysentery are as follows in different foreign stations : — 1. West Africa. 2. Ceylon. 3. Tenasserim Provinces. 4. Madras, Bombay, and Bengal. The relative prevalence in these divisions of India I have already shown. 22 TROl'ICAL DYSENTERY AND DIAUKIKEA. 5. Nova Scotia and New Brunswick, with Windward and Leeward commands. 6. Malta. From the foregoing facts it will be seen that both diseases are frequent, severe, and fatal in India among soldiers ; and as the conditions of life under which these, for the most part young and vigorous men, live, are favourable, this may be regarded as a faii'ly good illustration of the extent to which the disease prevails. I have said enough now, I think, to show that dysentery is almost universal, though more prevalent in certain parts of the earth than in others. That it is endemic, and often assumes a widely spreading epidemic character, in tropical latitudes, while it is comparatively infrequent and slight in others. It is not confined to the localities referred to in the official reports, but may be met with in Australia, the Americas, South Africa, Egypt, Ai'abia, the shores and islands of the Mediterranean, the South of Europe, and in fact anywhere, and is capable imder certain conditions of becoming epidemic. It appears to be less severe in hilly countries and above certain elevations ; whilst in alluvial plains and valleys, especially where there is malaria, it is more so ; and there are certain regions even in the tropics which, from some physical peculiarity of soil or of climate, seem to be exempt. It is needless to occupy more time in describing the geo- graphical distribution, and I shall now consider the question of causation. First, let me define dysentery. Dysentery may be defined to be a febrile disease, the result of the action of various noxious influences, or of a specific miasm, on the body mider certain predisposing conditions. Constitutionally it presents j)yrexial and nervous phe- nomena ; locally, hyperaemia, inflammation, exudation, ulcer- ation or sloughing of the coats of the large bowel, with certain pathological changes in the glandular follicles, in some cases extending into the ilemn, accompanied by nausea. LECTURE I. 23 tormina, tenesmus, scanty but frequent evacuations of gela- tinous or sanguineous mucus, of sero-sanguinolent or of muco-purulent matter and blood, mingled with faeces of a peculiar odour; in tbe later stages, of shreds or masses of sloughs, sometimes involving large portions of the gut. It may terminate in resolution and rapid recovery; or pass into inflammation, exudation, ulceration, sloughing, or gangrene, when it is dangerous or rapidly fatal ; or it may cause a chronic condition of thickening, idceration, and cica- tricial constriction, which is tedious, and may be ultimately fatal. It may be complicated with other diseases. Several forms are described — sthenic, asthenic or adjTiamic, cataiThal, fibrinous, diphtheritic, contagious, non-contagious, sporadic, endemic, epidemic, acute, chronic, malarious, ca- chectic, hepatic, haemorrhagic, erysipelatous, slougliing, gan- grenous or malignant, t}'phoid, and so on. These merely express phases or complications of the- same disease-process, which always involves some part of the large gut as the seat of the essential local expression of a constitutional disease, true dysentery. There is a tendency to involve other organs or tissues in the dysenteric process — e.g.., the serous membranes, kidneys, lungs, liver, spleen, etc., — or there may be septic infection by absorption from the diseased intestine. Tropical endemic and epidemic dysentery differs fi'om the sporadic form chiefly in degree ; the morbid process is otherwise the same in both. Under certain conditions it would appear to be infective. Etiology. A great variety of opinions have been held as to the cause of dysentery, and many forms of it have been described. For example, Zimmerman recognized the inflammatory, the bilious or putrid, the malignant, and the chronic. Until the time of Willis and Sydenham, ulceration of the intestine was regarded as the essential element of the disease. They, with Pringle and Morgagni, aver that ulceration is not the 24 TROTICAI. DYSENTEllY AN]) DIAKIUKKA. gravamen of the disease ; that either it does not exist at all, or very slightly. The disease, said Piingle and Sydenham, is essentially due to acrid humours in the blood. Degner considered that it was due to corrupted bile ; Willis, miasmata in the blood ; Stoll, in 1789, that it was due to rheumatism of the intes- tines. The last-named described five species — inflammatory ; the summer, which he subdivided into three — the bilious, the putrid, and the malignant ; the intermittent ; the sporadic ; and a fifth, which follows diarrhoea, of which it is only an exaggerated phase ; he also added two other forms — com- plicated, that is, bilious and inflammatory combined ; and the seventh, which, with Willis, who observed it in London in 1670, he named serous dysentery. Broussais and Pinel considered it an inflammation, more or less violent, of the large intestines — a colitis, in fact. Such may be taken as examples of some of the views formerly held as to the nature and origin of this disease. Fouquet, who wrote on Dysentery in 1852, says that it is neither intestinal rheumatism, nor ulceration produced by bile, acrid or putrid discharges according to the older writers ; nor a fever thrown on the intestines, according to Sydenham and his school ; nor is it simply coKtis ; nor an eruption of a pustular character, produced by an acarus, according to others ; but that it is a spasmodic disease of a clonic character, whose seat is in the great s}Tni^athetic, localized and manifested in the great intestine — an affection in which there is diminished general sensibility, exaltation of the contractile muscular movements of the intestine, and increase of the nmcous secretion, and that when the spasms attain a certain intensity and diu'ation, they determine organic lesions of a grave character. He says, moreover, that the indications for treatment founded on this theory are to allay spasm, to restore the normal state of the nerve-cen- tres, and subsequently, the consideration of the intestinal lesions. As to the cause, he saj^s that it is produced by dis- t urbance of innervation in various ways, and, admitting that the causes usually assigned are efficient, they are so by their LFXTURE I. 25 action on the nerve-centres, and that the same effects may be produced by other and totally different causes. He denies entirely that dysentery is contagious, and says : — " Pour mois je n'ai jamais vu la dysenteric devenir contagieuse, quelle que flit la gTavite de I'epidemie je n'ai vu ni les infirmiers, ni les soeurs, ni les medecins la contractor de cette maniere. Je ne I'ai vue se repandre par contagion, ni dans les maisons particidieres, meme les plus sales, ni dans les hopitaux les plus encombres et les plus mal tonus, ni dans les vaissaux oil les rapports sont continuels, oii les memes fournitures sont communes a tons les malades. Si elle s'est repandue d'une maniere contagieuse en apparence dans des villes assiegees, dans des camps ou regnait la famine, dans des cii'constances exceptionelles ; n'est il pas plus rationnel d'en attribuer I'origine et les ravages soit aux aliments de mauvaise nature, soit aux affections morales, soit a d'autres causes.". . . . " Ce qii'il y a de certain, c'est qu'on ne la contracte pas pour avoir touche le corps ou les habits d'lin sujet qui en est affecte.". . . . " Ainsi non seulement la dysenterie n'est pas contagieuse ; mais il n'est pas encore certain qu'elle puisse se transmettre d'une maniere quelconque d'un sujet a un autre.". . . . " Mais quand nous admettrions avec les contagionistes que les emanations des selles des dysenteriques produisent la dysenterie ; quand nous croirons avec Desgenettes et avec Vignes que les miasmes degages des substances animales en putrefaction la developpent ; quand nous reconnaitrons avec Zimmerman que le flau' d'un sang corrumpu dans une bou- teille la fait naitre ; ne savons nous pas que I'action des miasmes s'exerce principalement sur le systeme nerveux de la vie organique. Les emanations animales peuvent produire des spasmes ; et si leur action est trop forte ou longtemps continuee, donner lieu au typhus, maladie ou les desordi-es nerveux sont en meme temps si varies et si profonds, ou Ton observe tantot im aneantissement, tantot une exaltation partielle de cette innervation, et toujoiu's un trouble grave dans le systeme nerveux cerebro-spinal et dans les nerfs ganglionnaii'es. La fievre inteimittente dont le foyer est 26 TKOl'ICAI, DYSKXTEIIY AXI) DIAUIUKEA. dans le sjsteme nerveux, n'est elle pas produite par un empoisonnement miasmatiqiie ? Tons les miasmes degages des substances en putrefactions sont des agents essentielle- ments pertiu'bateurs du systeme nerveux, dont ils tuent la vitaKte, ou dont ils soUicitent les plus violentes reactions. Les odeurs seules, lorsqu'elles sont fortes et concentrees, peuveut causer des spasmes ou les faire cesser." And so lie ascribes the origin to the operation of these causes on the nervous system. He explains the lesions that, sooner or later, occui* in the bowels as a consequence of the spasmodic condition of the bowels, and not as its cause ; and he dwells on certain anatomical and physiological reasons, as seen in the muscular arrangements of the sphincter, the upper part of the rectum, and in the ileo-colic valve. He says the ulcerations and diseased intestinal glands are no essential part of the disease, and points to the undoubted fact that in many severe and fatal cases no ulceration is found. These views, which are peculiar, are most worthy of consideration, though they do not altogether coincide with those of other pathologists, who regard the morbid condition of the glands and mucous membrane as essential character- istics of the disease. Its prevalence and severity in warm countries, where malaria, climate, food and water, are instrumental in causing other diseases, seem to point to a similar origin. That there is something in tropical climates favourable to the develop- ment of dysentery, appears from such facts as I have related. The degree of severity and prevalence in different regions would indicate local conditions as factors in its production, whilst its occurrence in cold climates woidd show that the specific or exciting cause may depend on something inde- pendent of heat or malaria. Dr. Maclean says : "It appears that many of the so-called ' causes ' of dysentery must be regarded more as acute agents of j)ropagation than of causation." " I believe dysentery to be caused by the action on the blood of a poison having a peculiar affinity for the glandidar structures of the large intestine. The poison I believe to be a malaria generated LECTUKE I. 27 in the soil by the decomposition of organic matter " ; and " just in proportion as we have banished malaria, so have we got rid of dysentery. For a long time the prisoners in Millbank were subject to visitations of dysentery at those seasons and in those states of atmosphere which most favour the decomposition of organic matter in the soil" — but, it should be added that its disappearance was coincident, also, with amended diet. The same may be said of England generally, for when malarial fevers prevailed dysentery was severe and frequent. Both have diminished in severity and frequency ; and now, when seen, they are so mild as to show that the activity of the cause has been reduced to a minimum. We are still ignorant of the natiu'e of malaria, though the researches of Tommasi, Klebs, and others are tending to show that it may be due to no miasm at all, but to an organism, a microphyte, developed in the soil, and found there, and in the lower strata of the atmosphere in certain localities and climates, which infects the blood, and being inoculated, causes a paroxysm of ague. We are ignorant, also, of the nature of the specific poison, if indeed there be one, that causes dysentery. But we know something of the active agents of propagation, and the circumstances under which it is likely to arise ; and that it is apt to be prevalent and severe wherever heat, moisture, and alternations of temperature are great, and where there is organic matter decomposing in a damp alluvial soil like that of Bengal. But we cannot assert that it is altogether due to these physical conditions, for there are examples of malarial fevers and dysentery abounding in regions having quite an opposite character, and many outbreaks in camps or other collections of men imder depressing conditions, but not in warm climates, such as the armies of England and France in the Ciimea during the bleak and inclement winter of 1854, where, as Kinglake says, " Worn down by hard toil, nmubed and lowered by cold and heat, suffering under wants so pernicious as to be too surely followed by scurvy, and assailed too by cholerine, by true cholera, by dj'sentery, by fevers, and by numberless other complaints, our army underwent, day by day, appalling 28 TROriCAT. DYSKN'IKRY AND DIAitKHiKA. deductions from strength," prove that the group of symptoms called dysentery may arise under many and varying condi- tions. It would appear that just as sanitary progress elsewhere has diminished its endemic severity, so it is tending to do the same in India, and there can be little doubt that local out- breaks are greatly under the control of preventive sanitation. Dr. Coates, Sanitarj^ Commissioner, in his report on Calcutta for 1877, says : " It is worthy of note how rapidly and decidedly dysentery, and indeed all chylopoietic disorders, have ceased to attack Europeans in this coimtry. The old reckless exposure to sim and rain, tlie heavy tiffins, midnight suppers, and stronger liquor drinking, have ceased in pro- portion. Agues are getting rarer every day." And it might be added, that official reports show its tendency to decrease imder the operation of sanitary laws. Still, the evening and morning damp and chills, and sudden alternations of tem- perature, of July, August, September, and the extreme cold night air and heavy dews of October, November, and December, acting on the poor, ill and insufficiently clad, badly fed population, who sleep on damp floors, and of whom a large proportion are broken- do\\T.i in constitution, subject them in very large numbers to the influence and fatahty of bowel complaints. Children and the aged are also very liable to sucemnb, especially to dian-hosa. Malaria, errors of diet, and bad water help materially to encourage these diseases." Dr. F. N. Macnamara, in his " Diseases in Himalayan India," page 129, saj's : — "Bowel complaints, mainly dj'sentery and diarrhoea, stand next to fevers as causes of mortality amongst the people. The group probably includes, on the one hand, many cases which ought to be recorded as cholera, and on the other, many which woidd more directly have been attributed to fever complicated A\'itli diaiThoea or dysentery. Malaria, exposm*e, unwholesome food, such as unripe fruit and new rice, and, above all, foul water, are active- causes of this group of diseases." And many other observers have recorded similar opinions. Dr. de Eenzy, Sanitary Commissioner, Assam, !roportion to the part of the large intestine affected ; most so, when the rectum is involved. This chronic dysentery is most exhausting, and completely breaks down the health and strength of the sufferer. It is a frequent som-ce of invaliding, and forms a con- siderable portion of the cases of chronic disease with which old residents in India are affected, and is very prone to pass into chronic wasting diaiThoea — of which I shall have more to say in my third lecture. Such are the characteristic sjmiptoms ; they are modified LECTURE I. 39 according to the type or fonn the disease assumes, or by accompanying ailments. Various types and forms of dysentery have been described, e.g., the sthenic and asthenic, under which every phase of the disease may be placed. The acute or inflammatory, attacking the young and vigorous, whether it be sporadic or epidemic, is sthenic ; the sloughing, scorbutic, malarious, hepatic, and chronic, with continued diarrhoea and ulcerated or thickened bowel, are asthenic. Yirchow divided it into the catarrhal or sero-pui'ulent, and the diphtheritic or fibrinous, many cases partaking, at one or other stage of their progress, of both conditions. These he considered to have each their peculiar course and termination, but that every case is catarrhal at the outset. In speaking of its pathology, I shall endeavour to illus- trate the most characteristic pathological conditions of dysentery by clinical histories of recent cases, and by morbid specimens. No line of separation really differentiates one iy^Q from another, but there are characters sitflficiently well marked to distinguish them practically. The acute form, whether it be sporadic or ciDidemic, presents generally the sjonptoms I have described, more or less severe, according to the circimistances of the case and the peculiarities of the indi- vidual. The symptoms that characterize the malignant or gangrenous, and also the chronic forms, have been re- ferred to. Malarious dysentery is that in which the patient suffers from the effects of malarial poisoning, with the ordinary symptoms of remittent or intermittent superadded, with complications involving the liver and spleen, portal con- gestion, aneemia, gastric in-itabilit}^, or functional derange- ment of the abdominal viscera. Under severe impressions of the malarial poisoning, as in the case refen-ed to in BmTuah, sloughing, phlegmonous or erysipelatous dj'sen- tery may set in, pro\T.ng most dangerous, often fatal, death being preceded by great depression and collapse. Again, when the disease becomes epidemic among crowded 40 TKomCAI, DYSKNTERY AM) I)[ARRH(EA. troops in the field or garrison, especially when the circumstances are depressing and nnfavourahle, as from defeat or overwork, had or defective food, and where there is want of proper rest and shelter, the condition may hecome most deplorable, especially if to the camp- dysentery be added scurvy, scorbutic cachexia, ansemia, dyspnoea, lassitude, exudations into the areolar tissue, pain in the limbs, petechias, lividity following the slightest bruise, bleeding and sloughing gums, and foctor of breath, with great general exhaustion ; and, added to these, ulceration in the great intestine, attended by haemorrhage. These make the condition an exceedingly sad one, and, though not so fatal as malignant or gangrenous colitis, cause great mortality, though, should more favourable circumstances arise — by which I mean improvement in the moral and physical con- dition of the men, the supply of better food, and prompt and careful treatment of all who present any indications of scorbutic taint — much alleviation is possible, and many lives may be saved. I saw such conditions among the beleaguered garrison of the Lucknow liesidency. Perhaps nothing, un- less it be the gangrenous form of the disease, gives a more striking illustration of destruction of the vital powers and disintegration of the living tissues. The cause that excites the dysenteric process in the glands of the large intestine seems to act also on the liver. Dr. Budd was of opinion that liver-abscess, when complicated with dysentery, was due to infection of the portal blood by the intestinal disease, and in some instances it may be so, esj)ecially when, as in the examples I shall relate, the abs- cesses are multiple. Such are really typical cases of pyaemia. And I woidd here remark that these so-called abscesses should rather be regarded as necrosis, than as ordinary abscesses, for if they be examined in their earlier stages it will be foimd that they are patches of dead tissue, which, if life had been prolonged, would have been converted into abscesses by suppuration taking place around the dead tissue which, acting as a foreign body, provokes the suppuration. Liver-abscess with dysentery sometimes assumes this form. LECTURE I. '41 and may be due to direct absorption from the bowel, or to systemic poisoning or embolism, as in other cases of pyaemia. This is by no means confined to the liver, for the spleen, the kidneys, or the lungs, and pleural or abdominal cavities, may be affected, and sero-puriform effusions may be found in the cavities. The researches of Martin, Macpherson, Morehead, Moore, Partes, Marshall, and others, show that hepatic disease is an occasional compHcation of dysentery in India and other mala- rious coimtries. Dr. Parkes says that " analysis of the secretion of the liver shows that it is more or less affected in every case of dysentery, but abscess is not the most frequent complication in tropical dysentery." Baly did not find it in any of the Millbank cases, neither did Rokitansky in his experience ; Dr. "Wilson found it rare in the dysentery of China ; Cheyne found it in the dysentery of Ireland in 1818 in four cases out of thirty; Martin says it was observed in the dysentery of the Pen- insular War, but was rare in that of the Crimea. The fact is, that the liver-disease is often independent of the bowel- ulceration, though due to the same cause, and it would be impossible to predict, if a number of men were exposed to malarial tropical influences, how many would suffer from dysentery alone, from remittent fever, from abscess or other liver-disease, or how many from disease composed of all these morbid states. Albuminuria is not a frequent accompaniment of dysen- tery, but it does occur, and in malarious cases probably more frequently than in others. Its import is always serious, indicating congestion, and tubes loaded with exudation ; but I am inclined to think that slight albimiinm'ia is not always of so grave a nature as may be supposed. The spleen, also, may be involved, and assume the ordinary form of enlargement, so common in malarious poisoning which is always productive of anaemia and cachexia, if dysentery supervene, it must obviously be more dangerous, where the tendency to ulceration and disintegration of tissue and haemorrhage is so great as it is in this state. 42 TROPICAL DYSENTERY AXD DIARRHOEA, But the spleen may be affected, also, by the cause of dysentery, and become the seat of embolism and abscess, or of softening. The lungs, directly affected by the dysenteric process or by septic absorption, may become the seat of lobular pneumonia, embolisms and local deaths, which end in abscess. The special symptoms of these conditions would, of course, be superadded to those of dysentery, and would render the prognosis more serious, • It is not always easy to distinguish hepatic complications from those of an inflamed and ulcerated transverse colon ; but the general concurrence of symptoms such as rigors, sweats, the rise and fall of temperatiu'e, indicative of pytemic abscess, and in large single abscess, which may take place in- sidiously and with little pain or disturbance of temperature, the physical signs of increase of size and bidging, would aid diagnosis. The danger, of course, in all such cases is great. It is to be remembered that the liver during dysentery or any other disease, or even in health, is more prone to be affected in the tropics than in cold climates, and this may partly account for cases in which dysentery and liver-abscess co-exist. Martin and others thought that liver-abscess was intimately connected with disease of the coecum, but this is not con- firmed by post-mortem examinations, for out of seventy-two cases where the csecmn was affected, in only twenty-two was there liver-abscess. Moore, in " Annals of Military Surgery," says that eight observers out of twelve recorded a percentage of 18, or 295 cases of liver-abscess in 1,532 cases ; other foui' give a ratio of 39 per cent., or 52 cases of abscess out of 131 cases of dysentery. Eighteen per .cent, is probably the correct ratio ; the large percentage is more likely due to all diseased conditions of the liver that have accompanied dysentery. Recent observations, I think, confirm this view of the relative fi'equency of hepatic abscess in connection with dysentery; and though, in some instances of multiple abscess, the condition may be due to septic absorj^tion, yet liver-abscess generally must be regarded rather as an expression of the LECTURE I. 43 general disease than as a du*ect consequence of dysenteric ulceration of the large intestine. It would appear, then, that in different climates, localities, and epidemics, it is more or less frequent, according to cir- cumstances, but that there is a greater tendency to it in India than in other climates. In malarious countries, liver- ahscesses frequently occiu- in association with remittent fever, without any ulceration of the bowel (Morehead). Mac- pherson gives the comparative frequency of liver-abscess in dysentery as varjang from 13 per cent, in the Greneral Hos- pital, Calcutta, to that of nearly 60 per cent, (according to Annesley) as occurring in Madras. Perforation occiu'red in llv per cent., and extension of mischief to the ileum in 13*2 percent. (Moore). A few words on the significance of the symptoms I ha-s-e described. The tormina and tenesmus are due to irregular and excessive spasm or peristaltic action in the different regions of the colon and rectum, and especially to spasmodic contraction of the sphincter and upper circular fibres of the rectum and ileo-colic valve. They vary in extent and degree, according to the part of the gut affected. Spasm in the rectum may extend to the neck of the bladder, and cause strangiuy, making the desire to mictiu'ate as frequent and as painful as that of defoecation. The griping and colicky pains are less severe when the cseeum only is affected, but the more the rectum is involved, the greater the tenesmus. There are cases in which there is comparatively Httle pain, just as there are others without ulceration or blood. The tormina and tenesmus are, indeed, the most dis- tressing and exhausting features of the disease, and it is one of the main objects of treatment to allay the excessive action which causes it, and to soothe and reheve the catarrhal congestion and ulceration. The abdomen, in the earlier stages, is sometimes distended ; later it rather sinks in, and when the disease has advanced, there is severe pain on pressm-e over the gut thickened by exudation and ulceration. In severe cases, the cessation of the pain, whether of tenesmus or pressiu'e, is an evil sign, for it denotes failing 44 TKOPICAL DYSENTERY AND DIAKHIKKA. power, probably grangrene. The abdominal pain may be due to extension of the inflammation to the peritoneum, which is indicated by the state of the abdomen and by other concomitant symptoms of peritonitis. The mischief in some cases extends into the small intestines, stomach, and duo- denum, giving rise to pain and diarrhoea like that of typhoid, whilst jaundice may be caused by the bile-ducts being catarrhally obstructed. Nausea and vomiting are frequently present. It is not difficult to understand why this should be the case, when the whole intestinal tract is sympathetically, if not directly, implicated. The evacuations are significant of the progress of the disease, and indicate the catarrhal or diphtheritic, ulcerative, and sloughing stages as they occur. The incessant tenesmus and discharges exhaust the patient, though the quantity of each evacuation is small — a few drachms only — yet in the day it amounts to a good deal. Clear, tenacious, viscid mucus, at times tinged with blood from the hyper£eniic mucous membrane, indicates the catar- rhal stage. As it becomes rosy-coloiu'ed, red-currant- jelly like, or stained with fsecal and bilious matters, or is sero-san- guinolent or sero-purulent in appearance, with clots of blood mingled with mucus, epithelium, bacteria, detritus of food, or foreign substances, giving the appearance of chopped meat, it shows that the disease is advancing. Or the stools may consist almost entirely of blood, depending on haemorrhage from ruptui'ed vessels ; or of muco-puruleut, or sanious fluid, sometimes pure pus, or muco-pus ; certain lumps, comj^osed of mucus and epithelial cells, which appear to have been moulded into this form in crypts, gi"ving them the appearance of sago or frog's spawn, with the addition perhaps of some remains of articles of food. These indicate fm-ther advance of the disease. With these from time to time are mingled foeculent matter of a greyish-yellow or dark green colour, according to the changes that have taken place by decompo- sition or chemical reaction in their passage through the intestines. As the disease progresses, other matters are mingled with the discharges, sloughs of various sizes, from the smallest shreds to pieces of ashy or dark-looking sub- LECTURE I. 45 stance of various fonns and sizes, from that of sixpence to a florin, or larger, in some cases tubular. These are either portions of the mucous membrane or of exudation. The discharges (apart from the discoloration caused by di'ugs) become dark, grumous and foetid, with a gangrenous odour. The exfoliation of these sloughs, which commences about the second week is, perhaps, of more frequent occiu'- rence than supposed, and the appearances presented by them are important in estimating the actual state and progress of the case. I shall describe them in my next lecture. In some cases the dejecta are apparently free from blood, or even mucus — they are pultaceous, of various earthy colours, and horribly foetid, ha\'ing passed over surfaces no longer yielding blood, but in a gangrenous or sloughing condition which yield their putrilage. Such cases are extremely dangerous. The prognosis in acute dysentery, if treated early, is generally favourable. The result is rapidly successful and complete. In the advanced stages it is more tedious and uncertain, and it must be borne in mind that tenesmus and excessive action themselves may cause exhaustion and death, for it has been found on post-mortem examination that no ulceration had occurred. When the disease becomes chronic, the prognosis is more doubtful, especially when it is complicated with malaria, scurvy, hepatic or other disease, and when it occurs in conjunction with splenic or malarial cachexia. Where extensive ulceration or gangrene has oc- curred, the prognosis is most unfavourable, and death occiu'S with all the signs of collapse, consciousness and intelligence being often painfully keen and present until the end. In my next lecture I shall describe the pathology of dysentery, and illustrate it by clinical histories of typical cases, and by morbid specimens of recent cases. LECTURE II. PATHOLOGY AND MORBID ANATOMY OF DYSENTERY. Mr. President and Gtentlemen, I purpose in this lecture to describe the patliology, morbid anatomy, and treatment of dysentery, and to illus- trate them by recent cases and specimens, taken chiefly from the Calcutta hospitals and from Netley. I have already alluded to the general condition, and have anticipated in part what belongs to the pathology of ordinary dysentery. There is nothing in the temperature that is t3q3ical, though in the acute attacks of vigorous persons, especially Eui'opeans, there is a certain slight rise of temperature, as there would be in an acute congestive or inflammatory attack of another kind. But, as it frequently happens in India that the disease is accompanied by malarious fever, we may expect the thermometric variations that characterize that fever, whatever form it may take — quotidian, tertian, remittent, or irregular — to occur. The temperature, therefore, is not symptomatic of the dysenter3^ but of the fever, which results from the same general cause. In complications, where the liver, spleen, or other viscera are affected — and especially if suppm'ation is occurring there — the phenomena of that process will be manifested by high evening temperature, morning falls, and sweating after rigors or chills, such as occm" in suppm-ation from other causes. I have ah'eady re- marked that the true pathological explanation of multiple abscess in the liver (such as that I shall place before }■ ou) refers it to pj'semia, and that it differs from that of the LECTVRE II. 47 insidiously forming liver-abscess, when there is very little alteration in the temperature, which may be only a degree or two above normal. In cases of sloughing dysentery, especially when the sloughs are extensive, and in hemorrhagic dysentery, when there has been much loss of blood, the temperature may fall below the nonnal standard. In perforation, the temperature at fu'st, dimng the shock, is sub-normal, but as peritonitis sets in, it again rises. This is quite apart from the dysenteric process, and the rise of temperatm^e cannot be regarded as typical of that disease. The seat of localization is chiefly in the large, but in scorbutic cases, and in others also, it may extend into the small intestine for several inches above the ileo-colic valve, and the whole intestine, including the jejunum, duodenum, and stomach, also may be involved in the catarrhal condition, whilst the viscera and serous membranes may suffer in the dysenteric process. The liver is especially disposed to suffer in tropical climates, and either ordinary or septicaemic abscess may occur. The spleen and pancreas may be enlarged, indu- rated, or softened, and become the seat of abscess. When dysentery is associated with periodic fever, the spleen is frequently enlarged ; and in such cases there is apt to be splenic cachexia, and the disease is of the asthenic type. The lungs are occasionally involved, and the remarks that I have made in regard to the natiu"e of the so-called abscesses in the liver apply to them. The bronchial tubes may also share in the dysenteric in- flammation, and their mucous membrane become the seat of puriform exudation in the finer tubes, with patches of lobular pneumonia dispersed here and there throughout the lung. There are other complications — the erysipelatous, scorbutic, and typhoid — and one sees the close analogy of the disease with typhoid and diphtheria, and that, as the seat of the localization in typhoid is the ileum, in dysentery it is in the large intestine. Does not the tendency of the disease to pass the ileo-colic valve, perhaps, throw some light on the patho- logy of the so-called typhoid in India, which, by some, is referred to chmatic causes, rather than to a si^ecific foecal 48 TROPICAL DYSENTERY AND DIARRIKEA. origin ? If climatic conditions can cause disease in the gland-struetiires of the large intestine, it needs no effort of imagination to suppose a similar process may occur in those of the small intestine, or that the disease may pass the ileo- colic valve and appear in the ileum. It is not difficidt, either, to imagine that the stress of the morbific agency may fall primarily on the glands of the ileimi, and so give rise to the enteric lesions which so closely resemble those of the enteric fever of our own latitudes. I do not assert that it is so, but I would suggest that those who regard the disease in India as always of fsecal origin should give the subject reconsider- ation. The lesions in the large intestine are the result of inflam- mation and exudation affecting the mucous, sub-mucous tissue, and the glandular stmctures of the gut and subjacent areolar tissue, which is infiltrated and swollen by effusion of serous, sero-purulent, or fibrinous matter, causing softening, ulceration, sloughing, or gangrene of the mucous membrane, which may extend to the tchoJc substance of the gut. Bleker dwells on the pathological importance of the exudation, which he says takes place for the most part info the tissues beneath the mucous membrane, though occasionally on the surface in a diphtheritic form, or as in croup. But of him more presently ! Yirehow describes a catan'hal or sero- purulent and a fibrinous or diphtheritic form, at the same time admitting that in many cases they merge into each other, but says, " that the lesions of dysentery can only be correctly understood when the two forms are studied independent of each other" (Heubner). Sporadic dysentery, he says, is chiefly catarrhal, whilst true diphtheritic or fibrinous dj'sentery occurs in epidemics and in the worst form of malignant and gangrenous dysentery. In the catarrhal form, which corresponds to Eokitanskj^'s follicular ulceration, at the outset there is hj^pereemia of the mucous and sub-mucous tissues. The surface is covered by transparent mucus tinged with blood. The membrane itseK is red, ^\ith dark points and patches corresponding to J.ECTI RE II. 49 folds in the mucous membrane, and when it occurs in the small intestine, to the valvulse conniventes. The sub-mucous tissue is swollen by the distended blood-vessels, but the rest of the intestinal coats are unaffected in the outset. The mucous membrane " is swollen and of a whitish-red colour, with red areolae roimd the follicles, which appear like little white knots. Where the swelling is considerable there are small apertures in the mucous membrane over the follicles. These correspond to depressions in the mucous membrane, and become filled with mucus when the mem- brane around swells" (Heubner). The sub-mucous areolar tissue is swollen and infiltrated with serous or sero-pui-ulent fiuid. The whole intestinal wall may become thickened from the same cause. From this stage of acute hypersemia, rapid recovery under favourable cir- cumstances may take place. In the next stage, purulent softening of the mucous membrane, which assumes an ii-regu- lar roughened surface, occurs. The elevations are of various shades of colour — red, yellow, greenish, black, bro"WTi — covered with viscid mucus. This appearance is partly due to the disintegration of the softened and ulcerated mucous membrane. The sub-mucous and muscular layers are thickened and infiltrated. The follicles are destroyed, leaving depressions, or apertures, or elevations around the follicles that have not perished in the ulcerative process. They are not all so much destroyed as changed, and the apertures get filled with plugs of mucus and cell-growths, which appear in the dejecta. The ulceration may be very extensive and fatal, but, when not so, cicatrization and repair follow. In Yirchow's fibrinous or diphtheritic form, or in gan- grenous dysentery, the changes are more serious. The intestine is intensely congested, the lumen diminished, and the whole tube thickened. The contents consist of a thin reddish fluid, mth some fsecal matter. The mucous mem- brane is reddish or whitish, and is covered with discoloured patches, and the natural appearance of mucous membrane is lost. There is infiltration of fibrous exudation throughout E 50 TROPICAL DYSENTEKY AM) DIARUTKEA. the tissues, which may invade the whole gut, when gangrene and death result. Most cases, however, are probably com- binations of the catarrhal and fibrinous, producing ulcer and thickening of the bowel. This causes the irregularly thickened state of the gut ; and from such cases, sloughs are thrown off and ulcers form. The site and extent of these ulcerations vary. The sigmoid flexure is a common site ; the coocum in certain cases, and the rectum in others, are the principal seats of it. In some severe instances the whole gut is involved, but it may occur at different periods in different parts of the bowel. The condition of chronic dysentery into which these cases often pass, is due to these structural changes in the bowel — i.e., to thickening and imperfect cicatrization of the ulcers, and to the permanently injured state of the glandidar structures. In referring to the condition of the abdominal and mesen- teric glands, I alluded to the fact that they are sometimes found to be enlarged. In cases of tubercular diathesis — a condition in which dysentery, it is said, I believe, is prone to occur — the glands, and indeed the sub-mucous coat of the bowel, may be the seat of such a deposit. The late Dr. Chuckerbutty, who di\ided dysentery into a great many forms, gives cases in his paper in the " Indian Annals of Medical Science" (vol. x., pp. 115, IIG), in which there was such tubercular deposit in the membrane and mesenteric glands, and in the lungs, in one case ; in another, he relates how the tubercular deposit was found, after death, in the large intestine itself, in the vicinity of the ulcers, under the mucous membrane, infiltrating the areolar tissue between it and the muscular coat. Dysentery is always a subject of anxiety when it occm'S during pregnancy. It is very prone to cause miscarriage or abortion, and the progress towards recovery is generally more rapid, after the ovum is extruded. It is less amenable to treatment in the early stages in this state, and in either chronic dysentery or ordinary dysentery serious symptoms are more likely to supervene in the pregnant woman than in others. LECTLRE II. 51 It also frequently complicates recovery after deKvery, and assumes a very dangerous condition, though happily, even in this form, it is under the control of appropriate treatment. Intestinal worms — lumbrici, e.g. — are a frequent accom- paniment of dysentery in Bengal, and their presence must tend to intensify the local irritation and to aggravate the disease. Bicker's description, where it differs from others, does so more in appearance than in reality ; but the various accounts of the morbid anatomy by authors are rather conflicting. Dr. Aitken sums up well when he remarks : " "When one says that it is a process of inflammation, exudation, softening, and ulceration of the mucous membrane, in which the solitary and tubular glands of the bowel are much, and probably primarily, involved, and in which other tissues and organs of the body and the viscera may take part, the most important conditions have been stated. The various kinds of mucus, blood, serimi, pus ; the extent and site of infiltration or exudation and thickening ; the colour, form, and extent of the ulceration, and the magnitude of the sloughs — all express differences of degree or progress in the disease." For my own part, I think its separation into cataiThal and diphtheritic is rather artificial than real ; the one passes into the other, or the two forms are so inseparably combined that, except in typical cases of the ordinary catarrhal or the severely gan- grenous, most cases of dj^sentery present a combination of both forms. We are indebted to the late Dr. Parkes for a description of the morbid anatomy and nature of the changes that take place in the intestinal glands and coats of the intestine. He showed that these structures are very early implicated, and that tiiie dysentery never occurs without ulceration being present. From investigations made in Moidmein, Bm-mah, he concluded that, first, certain alterations in the glands of the mucous membrane of the large intestine, and sometimes of the ileum, constitute the earliest symptoms of dysentery. Secondly, that in all cases not too far advanced the mucous membrane presented the appearance of numerous whitish K 2 52 TKOriCAL DYSENTERY AND DIAHKHfF.A. round eleYations, of a size varjdng from a millet seed to a eize so minute that only a lens can show the lesion. These elevations were hard, and, heing pierced, gave foiih a white excretion. Many of these had a hard black speck in the centre, and were surrounded by a vascular circle. Thirdly, that exudation sometimes occurred in points beneath the mucous surface ; that such points of exudation had a white appearance, vdth. contents similar to those of the solitary glands. The mucous surface over these points could be easily rubbed off, leaving an ulcer (Aitken). Baly, Cheyne, Abercrombie, and others, have observed similar changes in the dysentery of Europe, showing that the tropical so far resembles the European form of the disease. The tubercles, pustules, ulcers, described by Pringle, Broussais, Hewson, Davies, and others, as occurring in the camp-epidemics of the Continent, have their origin in the solitary glands. Dr. McConnell, of the Medical College Hospital, says : " The disease conmaences essentially and primarily in the gland-structures. I have had opportunities of seeing several cases — i.e., post-mortems — at a very early period ; and then the only visible alteration is in the solitary glands and follicles of Lieberkiihn : the former especially, which I have found enlarged to the size of small hazel-nuts, and filled with that glazy, semi-transparent, glue-like mucus which we almost always find voided v/ith the earhest evacuations diuing life in this disease." The more severe forms, in which the mischief extends into the small intestine, are most generally seen in tropical countries ; so are the inflammation, pulpy softening, changes in the mucous membrane, ulceration, sloughing, and exudation of tubular casts of a diphtheritic character. It is in such cases, too, that fibrinous exudations are apt to result in tliickening chronic ulceration, and in the train of wa-etched symptoms that result from the contracted, strietured, and in- diu-ated gut, found in some of the worst cases of chi'onic dysentery. The distinguished Professor of Pathology at Netley says : LECTURE II. 53 " There can be no doubt that the anatomical signs of true dysentery are inflammation of the solitary lenticular follicles of the large intestine, tending, in the first instance, to infarction — i.e., the intumescence and congestion, and subse- quently to ulceration and destruction of the gland-tissue. The disease, extending by a similar process, ultimately involves the tubular glands of the general mucous membrane, which tend to soften and to be cast off as a slough, exposing the sub-mucous connective tissue, or even the muscular coat of the gut. It is the mucous membrane of the great intestine, and especially that of the rectum and lower portion of the colon, which is the seat of these characteristic lesions. The exudative process is generally diffuse, involving the whole of the tissues of the mucous membrane in a diphtheritic process of infiltration. The diseased part looks as if it were covered with a bran-like coating, especially over the summits of the folds of the mucous membrane, which are deeply reddened by ecchymosis and injection, and infiltrated by the exudation. This bran-like coating cannot be scraped off without loss of substance, aud the sub-mucous connective tissue below is (Edematous and swollen." In scorbutic or other low forms of dysentery, " a diphther- itic exudation covers not only the mucous surface of the colon, but the surface of the ileum above the ileo-colic valve. This exudation corresponds with the course of the blood-vessels, ramifying from the mesenteric attachment transversely across the surface of the gut, and especially over the prominences of the transverse rugae " (Aitken). As regards the ulcers aud exudations of the bowel : the former are various in form and extent, from small circular patches to extensive ragged sui'- faces, cori'esponding to the amount of mucous membrane and sub-mucous tissue destroyed. They present different appeai'- ances and combinations, according to the extent of tissue disintegrated. The contractions of the gut that follow, where life has been saved, are sometimes exceedingly dis- tressing, and it is to these chronic ulcerations and thickening from infiltration of the tissues of the gut that the distressing conditions of chronic dysentery are mainly due. With 54 TROl'ICAI, ])YSENTP:KY AMI) DlAllRHa-:A. these changes, the abdominal and mesenteric glands are often enlarged. The nlcers are thus described by Dr. Aitken : — " The summary of the processes from which ulceration may proceed is as follows : — " 1. After intumescence, softening, and simple ulceration of one or several lenticular solitary glands. "2. After intumescence, softening, and sphacelus of many solitary lenticiilar glands and the intervening tissue in one mass. " 3. After softening of the tubular structure and the de- tachment of sloughs, ulceration follows the intumescence and germination of growths from the tubes which cover the sur- face — as croupous, catarrhal, or diphtheritic exudation — to which the name of aphthous erosion has been applied. " 4. After sub-mucous inflammation and new growth, with fibrinous and mucinous effusion. "5. After intertubular inflammation and inflammation surrounding the base of inflamed glands. " 6. After the fonnation of sub-mucous abscess. " 7. By changes of an ulcerative natrn-e commencing in the vascular exudation itself, as in scorbutic cases." The rectum is the part most affected, next the sigmoid flexure, then the coeeum ; but in bad cases the whole gut is involved, and the appearance, when examined after death, is that of irregular ulceration, blackened or otherwise thickened. Sometimes the ulceration seems to surround the gut in rings, as it were. There are excavated ulcers — ragged, cut-out looking patches — or small circular ulcers, taking their origin in diseased solitary glands. The melanic deposit is very common and characteristic. Bleker, who wrote an interest- ing paper on Dysentery in Batavia in 1849, describes it as an exudation process and gives most detailed descriptions. " The deposit takes place beneath and in the mucous mem- brane of the colon, particularly beneath the mucous mem- brane, between it and the muscular coat, in the shape of solid yellowish- white fibrinous masses." This follows the hypersemia. Next there is softening and expulsion of the exudation. The mucous membrane over it decays and LECTUKE II. 55 perishes. The exudation is then poured out into the cavity of the gut, and the mucous membrane itself is expelled. Cica- trization next takes place ; and under whatever form or cliaracter the dysentery appears, the pathologico-anatomical appearances are the same, though they may differ in form and extent. He says of the forms the exudation assumes — lamellar, lenticular, tubercular, annular, diffuse, and circum- scribed — it is under the mucous membrane, as a rule, and not on it ; but he appears to have admitted, in a letter dated February 20th, 1853, to Dr. Cantor in Calcutta, that " the exudation on the mucous membrane is now and then essen- tially croupous, the mucous membrane becoming lined with an exudation-tube like that of the trachea in croup " ; but he adds, " such cases are very rare here," i.e., Batavia. He refers to sloughs of mucous membrane and sub-mucous tissue in the following terms : — " The mucous membrane itself is thrown off in the shape of larger or smaller grey-brown or blackish flakes and shreds," as a result of the pressure arising from the sub-mucous exudation ; also, " The most dangerous and destructive form is the diffuse exudation. Here the mucous membrane becomes gangrenous to a greater extent In such cases the muscular coat is often entirely obliterated, and thoroughly dissolved or infiltrated in the exudation. Both the muscular and serous coats become equally gangrenous, and there follows perforation into the abdominal or pelvic cavities." " During life the stage is easily recognized by the flakes of exudation and pieces of the sloughed mucous membrane which occur in the evacuations." " In lamellar exudation it sometimes happens that the mucous membrane, by itself, or with the sub-mucous mem- brane firmly adhering, is voided in the shape of larger or smaller flakes." " In cases of lenticular, lamellar, and diffuse deposits, the exudation flakes, as he calls them, are small — commonly not larger than pins' heads. Some are of a consistence like gonorrhoeal matter ; others fij'mer, caseous, like half-softened tubercular substance." 66 TROl'ICAL 1)YSENTP:RY and I)IARRH(EA. With reference to the chemical composition of the dysen- teric discharges, I am not aware that any observations have been made in Bengal since I left Calcutta. Dr. Aitken says justly, it is very desirable that some observations made by (Esterlen, who describes an excessive amount of albumen in them, should be verified in India. If, says he, two ounces and a half of albumen are passed by stool in twenty-four hours, it is impossible to over-estimate the importance of its occiuTcnce. It is very necessary to watch the characters of the sloughs thrown off during the disease. When the dejecta are washed, and the fcecal portions separated, the residue consists of ropy gelatinous mucus, braimy shreddy deposits, sloughs of various sizes ; and, from their condition and appearance, the progress and variety of the disease may be ascertained. The late Dr. E. Goodeve, Professor of Medicine in Calcutta, made important observations on this subject, but has not, so far as I am aware, left any written account of them. I asked my friend Dr. N. Chevers, late Professor of Medicine in Calcutta, for any information he could give me as to Dr. Groodeve's views, and also for his own, as derived from his great experience, and the following is his reply : — " My late esteemed colleague. Dr. Edward Goodeve, is believed to have made very important observations on the dysentery of Bengal, but he does not aj^pear to have pub- lished his views, and I am not aware that they have ever appeared in print, unless they are represented in a paper by Dr. Chuckerbutty in the ' Indian Annals of Medical Science.' " I have strong grounds for considering that the following note embodies the leading observations of Dr. Goodeve. But whether this is or is not the case, can never now be fully proved, unless, happily, his lectirres, or a manuscript on the subject, shall be found among his papers." LECTURE ir. 57 Dr. Chcvers' Observations. 4 " By washing the stools throughout an attack of dysentery the follomng appearances maybe observed: — At the onset, the first or second dejection completely, or nearly so, evacuates all faeculent matter. " The stools then consist entirely, or with but slight traces of fteculent matter, of ' rose mucus,' of gelatinous consistence. At this stage, in most cases, the disease is readily amenable to treatment, as by ipecacuanha. This is generally the case with private patients, who, ha\T.ng been attacked at night, seek aid in the morning. In hospital cases the disease has almost invariably been neglected for some days pre\dous to admission. " In a neglected case sloughs are generally passed on the sixth or seventh day. These vary in size, up to that of a man's hand. In fair constitutions these sloughs often have much the appearance and consistence of a preserved oyster. They are oval, and nearly a sixth of an inch in thickness. They are made up of the whole depth of the mucous mem- brane, frequently backed ^\ith some of the muscular coat, the sub-mucous tissue being largely infiltrated with the products of inflammation. We know these as the ' pus- infiltrated sloughs.' When this kind of sloughing occurs extensively, nearly the entire mucous lining of the large intestine may come away in the form of ' tubular sloughs.' " In this form of sloughing, it is very remarkable that, formidable as the symptoms are, the patient's condition often appears to improve, as if in proportion to the quantity of slough got rid of ; but, in the end, there may be frightful puckering of the colon, and rectal stricture. " In this form of the disease, all the sloughs having sepa- rated, we find, on washing, more or less of ' branny mucus,' which is clear cN-idence that the case is rather far advanced, and that it promises recovery. In a few cases we find that the vessel contains a large quantity of mucus, which is quite transparent, and so tenacious that it may be di'awn out in 58 TROPICAL DYSKNTERY AND DIAHIUICEA. such a manner as to form a bridge between tlie brims of two utensils. We call this ropy mucus, as often happens in nasal catarrh. The presence of this mucus is, barrirtg accidents, a sign that recovery is almost completed. " The gangrenous colitis of Bengal — a disease which is usually mortal in from eight to twelve days — commences, as dysentery, with ' rose mucus,' but I have not seen either the * branny mucus ' or the sloughs described above. A few days before death we can usually discover a black or coffee- coloured sphacelated object, which almost pre- cisely resembles an old sooty cobweb rolled together and floating in the fluid. I often sent for such a cobweb and placed it beside the slough in the plate ; by outward view one could hardly be distinguished from the other. I believe that Groodeve regarded this as sub-mucous areolar tissue separated after gangrene. When these sloughs appear death is inevitable. I never knew an imfavourable prog- nosis fail in a single instance. With these sloughs there is more or less hasmorrhage. The stools now frequently resemble, in colour and consistence, cream mixed with blood. Once recognized, the penetrating foetor can never be for- gotten. After death, the large intestine is found lying like a dead snake ; there is almost universal sphacelus of the mucous and muscular coats, and this not unfrequently ex- tends to the peritoneal coating of the bowel. " I have never seen inflammatory coating of the mucous membrane of the large intestine in dysentery." I have nothing to add to this graphic account of an im- portant part of the morbid anatomy of dysentery. In the " Indian Annals of Medical Science," vol. xii., page 117, Dr. Ewart has written a description of the same subject, and it, like all his writings, bears marks of close and original observation, and is of great value. Dr. Chuckerbutty (" Indian Annals of Medical Science," vol. X., p. 90) describes the appearance of the dejecta and the import of each particular form of slough, and this accoimt is believed to represent Dr. Groodeve's views. I consider that any account of dysentery in India would be incomplete LECTURE II. 59 without reference to the investigations of one who made it an especial study; I therefore give them, i.e., Dr. Groodeve's views, in some detail, in nearly Dr. Chuckerbutty's own words. He says : — Molecular sloughs or putrilage show disintegration of tissue. Flaky epithelial sloughs indicate commencing of gangrene of mucous membrane. Thin black sloughs, plain or tubidar, show the primary gangrene of the mucous coat. Shreddy, ragged, and dark olive sloughs show gangrene in either mucous or cellular coat. Thick pus-infiltrated sloughs show erysipelatous dysen- tery — very dangerous. Grrey or light yellow sloughs, plain or tubular, show phlegmonous dysentery. Grrey, shaggy, thick sloughs show violent inflammatory action. Free gelatinous or cellular sloughs, when simple, show the presence of primary gangrene in the sub-mucous connective tissue ; when pus-infiltrated, that of sub-mucous cellulitis. Ring-shaped sloughs show ring-shaped ulceration in the mucous folds. Discoid sloughs show circular ulcers in ecchymosed patches. Ecchymosed sloughs show the presence of abraded minute ulcers and intestinal apoplexy. Nodular sloughs would show the presence of nodular follicular disease ; but these sloughs are very apt to be confounded with pieces of pus-infiltrated mucous sloughs of erysipelatous dysentery. Tubercular sloughs, if detected, would show the presence of tubercular dysentery. This, Dr. Chuckerbutty says, he has not seen. This seems rather an over-refinement of classification, but still it relates to what is actually seen where dysentery is frequent and severe, and it shows how much importance was attached to the study of the appearances of the sloughs, as an indication of the character and stage of the disease, by a 60 TROPICA], DYSENTERY AND DIAliRIKKA. physician of great experience, whose opportunities of study- ing it were unusually extensive. Treatment of Acute Dysentery. It is hardly necessary to say here that spoliative or de- pletive measures are not to be thought of in the treatment of dysentery in these days. Whatever may have been the prac- tice in past times as regards the use of mercmy or vene- section, it is no longer deemed expedient to resort to them. Even in the sthenic forms of the disease, it is, as a general rule, undesirable to abstract blood, unless such as may be taken by a few leeches applied over the course of the large intestine, and even then but very seldom ; whilst the exhibition of mercury, with the object of inducing its physiological action, is altogether to be deprecated. Time does not permit me to enter into any historical detail of the various methods of treating dysentery that have been in vogue in past times. They have been as varied as the theories of the disease itself, and the results have always been unsatisfactory, for it has been, and indeed still is, one of great fatality, hardly exceeded by any other in proportion to the number attacked. But the last quarter of a century has witnessed considerable progress in the therapeutics of dysen- tery, and we now know, that if it be dealt ^yith in the very outset, there is probably none more amenable to treatment. I shall not attempt to describe the methods of treatment that have succeeded each other since the days of Hippocrates, who, attributing the disease to acrid juices and believing that the ulceration of the intestines was merely a means for effecting their expulsion, treated dysentery with laxatives, diluents, and the like. It is needless to recapitulate to you the teaching or practice of the advocates of bleeding, mer- curialism, astringents, and a farrago of drugs and nostrmns that proved alike futile and unsatisfactory. I might, per- haps, with more advantage, advert to the recognition of its malarial origin, as proof that one importayt cause had LECTUKE II. 61 suggested a rational treatment to Morton, when, in the seventeenth century', he availed himself of the antiperiodic virtues of Peru%dan hark as a therapeutic agent, in which he was followed by many other eminent physicians ; but it would be superfluous, wasteful of time which I could ill afford, and tii^esome to you to do so. Suffice it to say that each new plan, having failed, gave place to another, and that dysentery continued to be in- tractable, and to frustrate the best efforts of physicians, until a medical officer of the British Army revived attention to the use of a drug that had long been kno'svn as a remedy for dysentery. Disappointed with the results of all treat- ment, and being convinced that bleeding, purgation, mercury, opium, astringents, and the like, all fail to give any satis- factory results, he determined to try the effect of repeated large doses of ipecacuanha alone, and being at the time in charge of his regiment in the Maiuitius, where dysentery prevailed, he passed from reflection to experiment, and found the remedy so successful that, from that experiment, the results of which were published in the Lancet of July 31st, and August 14th, 1858, has arisen an important revolution in the treatment of this dangerous disease. It seems to me that this gentleman did an inestimable ser\ice to medicine and to humanity, but it was not until last year that he succeeded in obtaining any recognition of the important services he had rendered to the State and to mankind, when, at the urgent request of the Director-General, a gratuity of £400 was granted him ! It would be interesting and perhaps not impossible, to compute the probable amount of hmnan life preserved and money saved to the State by this officer. Let me read a memorandum on the subject furnished by competent authority, and you can judge for yoiu-selves : — " Mr. E. Scott Docker, while serving in Mam-itius, previous to 1857, as Surgeon to the 5th Fusihers, adopted a mode of treatment for tropical dysentery which was so successful that he published the results in the Lancet in 1858. " His method, which consisted in administering large doses 62 TROPICAL nYSENTEKl AND DIARKHfEA. of ipecacuanha, was at once taken up by army medical officers in India, with a result that is more than satisfactory. For the ten years previous to the use of this remedy, as recommended by Mr. Docker, the death-rate for dysentery among British soldiers was very large, averaging 107 per 1,000 cases — that is, nearly 11 per cent, of the cases of dysentery were fatal. " The mortality, on its adoj)tion, fell at once from 81 per 1,000 in 1859 to 54 in 1860, and during the ten years subsequent to its introduction the mortality-rate averaged 47 per 1,000 cases, or less than 5 per cent, proved fatal, and at the present time the death-rate is even lower. " The recovery, moreover, is not only much more rapid than under the methods previously used, but is also more complete, and a relapse may be considered as rare. The remedy is equally effective when the native soldier is subjected to it, and the saving not only of life by its introduction has been immense, but that also of money, to the State, becomes apparent." Dr. Joseph Ewart and others have shown how greatly the mortality has been reduced ; and it is well known to medical officers who have served in countries where dysentery prevails or is endemic, that if the disease be treated early with full doses of ipecacuanha, acute dysentery is as tractable as, or more so than, ordinary diarrhoea. Hear what Dr. Iv. McLeod, of Calcutta, says in a recent letter, and I am sure that others could, as I can, confirm his statement : — " I have had a number of cases of acute dysentery this year, 1880, in which large doses of ipecacuanha were followed by iiin/i/'- diate or speedy recovenj. In one case, a man was taken ill on Saturday, had his ipecacuanha on Satiu'day night, and was able to attend office on Monday." " These," says Dr. McLeod, " are cases of catarrhal dysentery, I suspect. An acute case of dysentery, however severe, ought to get well under proper, i.e., ipecacuanha, treatment in a week. The most troublesome and obstinate are cases of rectal dysentery with haemorrhoids, and perhaps rectal ulcers. I have tried ergot in these cases, and found it answer better than LECTURE II. 63 ipecacuanlia ; but rectal medication is the most successful." In the former part of Dr. McLeod's remarks I quite concur, for it accords with my own experience. About the ergot I am not so sure, for I have not had much experience of it. The ulceration and other structural changes, which are the results, rather than the disease itself, are less easily dealt with ; but even when they are established, if there be, as unhappily there sometimes is, a recuri'ence of the acute symptoms, then ipecacuanha is again needed. I feel sure you will agree with me that we owe a debt of gratitude to Mr. Docker for his important contribution to the thera- peutics of dysentery ; and I am sure there is no assembly where this claim to recognition could be better estimated, or where it would be more freely or generously accorded, than in this Society. Ipecacuanha had long been known as a remedy for dysen- tery ; indeed, it was called the " radix anti-d//senterica," and had been used in India in small doses, combined with blue pill, gentian, and other remedies, and no doubt with good results : its revived use in late years, therefore, cannot be regarded as altogether a novelty ; it is for establishing the fact of its utility in frequent large doses of the powder that we are indebted to Mr. Docker. As Mr. Justin Maearthy says of Cyrus Field, in regard to the Atlantic cable, " It was not he who first thought of doing the thing, but it was he who first made up his mind that it could be done, and showed the world how to do it, and did it in the end ! " — (" History of Our Own Times," vol. iii., p. 90.) Ipecacuanha was first brought to Europe in 1658 by Piso, who gave it, in doses of infusion of one drachm of the powdered root, in dysentery. Otlier pliysicians followed his example, and the practice was adopted by Friend, Pitcairn, Brockelsby, Boulduc, Balmain, Wentworth, and others since. Wentworth, indeed, gave very large doses — ninety grains combined with opium. Bateman gave it in doses of two drachms, but combined with one di-achm of tr. opii, " and in many cases," says Dr. Ewart, to whose interesting paper on the subject in the " Indian Annals of Medical Science" I refer you, "I found that a dose or two was 64 TROPICAL DYSENTERY AND DIARRHCEA. sufficient to remove every dangerous symptom." In 1813, Mr. George Playfair, in Bengal, gave half-draclim doses, combined with half a drachm of tr. opii, and repeated the dose until the stomach became tolerant and the dysentery disappeared. English prescribed one scruple to half a di'achm, with double this quantity of laudanum. In 1818, Copland gave eight to ten grains of -ipecacuanha with. opium, sometimes with calomel or blue pill, with the best results. Mortimer, in Madras, and after him Annesley, Twining, R. Martin, and other Indian medical officers, adopted ipecacuanha in small doses as a remedy with which they treated dysentery. But it was not until 1857 — Docker's time — that it began to attain the celebrity it still maintains as a remedy to which all others are of secondary importance in treating acute dysentery. The rationale of its action is explained by Dr. Ewart in nearly the following terms : — " In large doses it stops inflam- matory action, augments the alvine secretions from oesophagus to rectum, increases the flow of bile and pancreatic juice, pui-ges without irritating, lessens peristaltic action, produces rest, restrains tomiina and tenesmus, promotes diaphoresis, restores the balance of the poi-tal circvdation, is a direct sedative of cardiac action ; acts on the glands of the stomach and duodenum, pancreas, liver, and small intestine, and on the glands of the large intestine." It is doubtful whether the nausea and emesis it causes are beneficial — I have always felt disposed to think that they are so — at any rate, they do not interfere v^ith the action of the ipecacuanha. " It produces all the benefits that have been ascribed to blood-lettmg, without robbing the system of one drop of blood ; all the advantages of mercurial and other purgatives, without their irritating action ; all the good results of antimony and other sudorifics, without their uncertainty ; all the benefits ascribed to opium, without imtating, if not aggravating or masking the disease." But as Dr. Ewart also says : " Much remains to be elucidated before the true ph^'siological action of the remedy can be fxdl}^ understood." LECTURE 11. 0-J For my part, I am disposed to believe that it is by its general effects, rather than by any direct specific action, that it proves useful. The treatment of an attack of ordinary acute dysentery is to be conducted on the following plan : — The patient should remain in bed or in the recumbent postui'e ; if there be abdominal pain or tenderness on pressure, hot fomentations or turpentine stupes should be sedulously applied. A dose of twenty or thirty grains of ipecacuanha powder, according to age, strength, etc., should at once be given to an adult, in water, and the patient should endeavour to resist vomiting as long as possible, — though for my part I am inclined to think the emesis does rather good than harm. It may be well to combine ten grains of carbonate of soda with the ipecacuanha, to neutralize acidity. It is recommended by some to give a dose of fifteen or twenty drops of laudanum before the ipeca- cuanha, and to apply a sinapism to the epigastrium, with the view of diminishing iiTitability of the stomach and of pre- venting sickness. He must abstain from all fluids except occasional mouthf uls of iced water or bits of ice to allay thirst, which is often intense. My own plan has generally been to repeat the dose of ipecacuanha in four or six hours — a second or third time, according to the eifects ; and especially if the first dose has been speedily rejected, as it often is. I have generally foimd that if this treatment be resorted to early in acute dysentery, it is most effective, and nothing else is needed. The pain diminishes, the tormina and tenesmus are alleviated, the restlessness is abated, the sense of fidness and desire to go to stool passes away, the skin becomes moist, and in all respects a general sense of relief is experienced. The motions become f geculent and assume a peculiar yellow appear- ance, significant of the action of the remedy. If any irrita- bility should remain, a dose of ten or fifteen grains of Dover's powder is beneficial ; it gives ease, sleep, and aids in the restoration of the natiu'al action of the bowels. Small doses of castor oil — half an ounce or less — are given occa- sionally, and by some are considered of importance. No doubt if there be inaction of the bowels after ipecacuanha, or V 66 TROPICAL DYSEXTEllY \yi> DIARRHOEA. if it be necessary to aid in expelling mucus — for the in-egular contraction of tenesmus is not always efficient in this respect, — the castor oil is most desirable ; or if there be indications of hepatic or portal congestion, sulphate of soda or magnesia would be better. A certain amount of nourishment should be given, but it must be fluid, and of the most bland and iminitating charac- ter — animal broths, milk and soda-water or lime-water (for milk alone vdU hardly be tolerated), and arro'svroot. Fari- naceous food, however, as a general rule, does not agree, and it is better to adhere as nearly as possible to broth and milk. In the acute stage, at the outset this alone is necessary, and all remedies of an astringent or sedative nature are un- necessary. It is quite possible that there may be a recurrence of the acute spnptoms ; in which case the ipecacuanha must again be given, though it may novv^ be in smaller doses of ten or fifteen grains — the recimibent ^Jostiu'e and the carefidly regu- lated diet being rigidly observed, \vitli fomentations, and ten grains of Dover's powder at night ; or an injection of starch and thirty or forty drops of laudanimi. ^Vhen the disease has advanced to idceration, and when the chronic stage has been fully established, the ipecacuanha is no longer usefid. In the case of private patients among the intelligent classes, and soldiers or others under control and observation, we are generally in a position to deal with the disease in the catarrhal stage, but not always, and some do not appear until the catarrhal stage has been overpassed, and a condition more difficult to deal ^^ith been established. In such cases where, from delay in treatment, or when the disease has been neglected, either the congestive exudative stage continues, or ulceration has begun, it may be necessary to continue the use. of ipecacuanha, though in smaller doses of foiu' or five grains, and it may be then expedient to combine it with other drugs. Dover's powder, alone or combined with quinine, and, it may be, ten or fifteen grains of soda or bismuth two or three times a day, substituted, especially at night. Mj' old fi-iend, LEfTlRK II. 07 Moulvie Khan Bahadoor Tameez Khan, speaks of an extract of some euphorbiaceous plant, common in Bengal, as a remedy in dysentery, and gives some cases in which it was used with apparent advantage ; but he does not speak enthusiastically of its utility, nor do I see much e^ddence in support of it. The powder of Calotropis gigantea, of the same family, has long been one of the Indian remedies, but I cannot say that I know much of its value in the treatment of dysentery. Complete rest, not only of the body, but of the intes- tines, is necessary, and for this reason the recimibent posture, and remedies that allay muscular spasm, are necessary. Judiciously used, opiimi may be of great benefit, but, as a general rule, it is better to avoid the use of it, as much as possible, for it inhibits that which it is our object to produce — free secretion. Dysentery in the acute form having passed away, may merge into dian'hoea ; which, to some extent, may be due to the ipecacuanha. This, if it do not raj)idly subside, may be controlled by any simple astringent, such as chalk mixture, catechu, kino, haematoxylin, the red eucalyptus, "svith bael ; but it is ouJi/ in this condition that astringents are of advan- tage ; in the early and acute stages they are out of the question. Most cases of dysentery, in Bengal at least, are more or less associated with malaria, and therefore quinine is a desirable adjuvant to other drugs ; and in cases where the malarial indications are well marked it may be expedient to give it in large doses. Mr. Hare, the Surgeon of the 1st Bengal Fusiliers, advocated its use most warmly, not only by mouth, but as an injection, and his results certainly appeared to confirm the justness of his \iews. Less importance is attached to them now, but still the value of quinine in mala- rious dysentery is fully recognized, and it should be, and is, given alternately with the ipecacuanha imtil the ph^'siological action of both has been manifested. Again, in the splenic form, sulphate of u'on may be combined with advantage ; but it is to be remembered that neither quinine nor iron are likely F 2 68 TROPICAL DYSEXTERY AND DIARRHCEA, to be of any service if they are given when the portal system is congested, or when the intestine is in the state of engorge- ment of the catarrhal process. A great difficulty in cases of debihty often naturally arises about giving the ipecacuanha, but it is better tolerated than might be supposed, even in the weak and anaemic ; and its use may be preceded by some cordial, whilst support may be given afterwards by the same means, for, though otherwise depressing, ipecacuanha cer- tainly removes the fons et origo niali, and so with a little evil does great good. Where the dysentery is of the scorbutic form, it is necessary to improve the condition of the blood by the use of better food — vegetables and fruit. Astringents also, with mineral acids, may be expedient, even in what corresponds to the acute stage. At the same time, Dover's powder, or even ipeca- cuanha alone, may be useful. Under this treatment, the dysenteric symptoms abate, with the general improvement in health. In such conditions the bael or the koorchee* are certainly useful with the Dover's powder. But whenever the m'gency indicates any great access of inflammatory mischief or congestion of a catarrhal nature in the mucous membrane or around the ulcers, the ipecacuanha must be again resorted to. When the catarrhal or congestive follicular stage has passed into the ulcerative stage — that, indeed, which is the condition in the greater part of the cases that have been neglected at the outset, or have not }delded at once to treat- ment — the question is, What is to be done for these ulcers, this thickened state of the bowel, etc., before the disease has passed quite into the chronic state ? The object is to give rest, to support the strength, to avoid all irritation and recun'ence of inflammatory action. Turpentine in small doses, twenty drops three times a day, with a certain amount of opium, and local medication, with argent, nit. injections, and, where the rectum is implicated, with ergot injections and opiate enemata to allay tenesmus and pain. Large enemata of tepid water are also usefid. It will take time for the ulcers to heal, but it is remarkable * Bael, or ^gle marmelo.s ; Koorclieo, or Wi'icchtii anti-dysenterica. LECTURE II. 69 how rapidly they seem to do so under favourable circum- stances and cai'eful attention to diet and treatment. Any recurrence of acute dysenteric symptoms indicates the need for ipecacuanha. In advanced cases, where ulceration and sloughing have commenced, the use of ipecacuanha is contra-indicated, whilst opium or Dover's powder, to the extent of allaying pain or irritation, will be necessary, but care must be taken to avoid opiimi intoxication. It has been recommended by Waring to combine it in small doses with small doses of nitrate of silver ; but I cannot say that in my own experience I have seen any special benefit derived from this remedy, though in some chronic cases it may have proved usefid. In htTemorrhagic dysentery, where the loss of blood is great, ergot as an enema, twelve or fifteen grains in starch or arrowroot, has been found efficacious. If the haemorrhage be profuse it may be desirable to use tannin in the same way ; but otherwise, astringents are contra-indicated in acute dysentery. Preparations of iron with calumba are often usefid during recovery, and the greatest care must be taken to avoid any error in diet, which for some time must be of the simplest kind. Rest and diet are most important elements in the treat- ment in the early stages. The food must be of the blandest and most simple character, and all solids should be avoided. This is equally necessary in the sloughing and ulcerative or gangrenous stages; but here it is essentially necessary to support the strength, and animal broths are desirable, with a certain amount of vrme or other alcoholic stimvdant as may seem most expedient and suitable to the habits of the patient. In cases where the inflammatory action is sthenic, and where the pain is great, the use of a few leeches over the swollen and tender bowel may be useful ; but I believe such cases to be quite exceptional. Opiate enemata at night, to give rest and relieve the tormina and tenesmus, will often be beneficial; but again I woidd say that it is necessary to beware of inducing narcotism. 70 TKOPICAJ, DVSKM'EKV AND JJJ AKKIIQ. A. In malarial cases I have already said that quinine is necessary. It should be given until the patient is cinchonized, whilst paroxysms of fever shoidd be anticipated by the exhibition of full doses of ten grains ; some give twenty. In cases of dysenteric liver-abscess, if the abscess point or become sufficiently apparent to justify the operation, it should be freely opened antiseptically, and the pus di-awn off through a di-ainage-tube ; but the probability of the abscess being multiple should be borne in mind, and that if it be so there is not much hoj^e of permanent benefit. Still, it is possible that it may be single, and no prospect of affording relief should be neglected. There are cases in which, though the success may be only partial, yet, if it afford any prospect of relief, the operation should be per- formed, antiseptic precautions being observed ; and there is every reason to believe that the operation is attended mth so little risk that even as a measm'e of temporary rehef, even though it cannot save life, it is expedient. I shall now request your attention to the clinical records and morbid anatomy of some recent cases and specimens, for which I am indebted to friends in Calcutta and at Netley. Time will not permit me to relate all that I have here, so I must select a few cases in which the symptoms, treatment, and pathology are tj^ically represented. Case 1. — Catarrhal Dysentery. Second Physician's AVard, Medical College Hospital, Calcutta ; Dr. Chmidra. W., a Mahomedan male, aged thirty-eight, a labom^er, was admitted into the Medical College Hosj^ital, for an attack of dysentery, on March 2nd, 1880. History. — Had been suffering from looseness with griping for a fortnight. The stools, about twelve in twenty-fom* hoiu's, contained blood and mucus. LECTLKE II. 71 Is healthy-looking. Tongue moist and clean. There is pain on pressure over iliac fossa. Stools contain no feeculent matter, but a large quantity of jelly-like mucus, deeply tinged mth blood. Pulse small, soft and weak. No splenic enlargement. A dose of castor oil A\dth tinct. opii was given, and a powder containing bismuth, ipecac, and sodse bicarb., five grains each, three times a day, ordered ; milk and sago diet. March 3rd. — Morning : Four stools, consisting of mucus, blood, and small pieces of slough. Evening : Three stools ; green faeculent matter, with less mucus and blood. 4th. — Stools fcecideut, %vith traces of mucus and blood. 6th. — Four loose, bilious, and fteculent stools ; no mucus or blood. Powder omitted, and bael and koorchee mixture ordered, three times a day. He rapidly recovered, and was discharged on March 19th. Simple catarrhal dysentery, well in seA^enteen days. Case 2. — Catarrhal Dysentery. T. S., a European seaman, aged twenty-one, admitted on November 30th, 1878, into Medical College Hospital, Cal- cutta ; discharged December 5th, 1878. History. — Had been siiifering fi'om dysentery for ten days. Stools scanty and very frequent ; contain only blood and mucus. Healthy -looking ; tongue moist and coated ; pulse full, soft, and regular. Passed about six stools within haK an hour. They contain faecident matter with shreds of mucus and blood. No pain in the abdomen. On admission a large water enema was ordered ; bismuth, ipecac, and soda, five grains each, three times a day. December 1st. — Had one stool after the enema, and five stools since last night. They contain a large quantity of shi-eddy mucus and blood. 2nd. — Stools unchanged in character. Vomits the powder. Ordered a di-aught containing tinct. opii and spt. chloi-ofonn, to be taken half an hoiu" before each powder. 72 TROPICAL DVSEXTEKY AND DIAKRIICEA. 3rd. — Eetained the powder. Had four stools containing biKous fseculent matter and traces of mucns and blood. 4th. — Had no stools last night. 5th. — One formed stool. Discharged. Well in five days. Duration of the disease about fiiteen days. Case 3. — Catarrhal Dysentery. S. K., a Mahomedan, aged twenty-five, was admitted on March 6th, 1880, Medical College Hospital, and discharged on the 15th. Had been suffering from dysentery for a fortnight. Passes about twelve stools in the twenty-four hours, containing blood and mucus. Condition on Admission. — Is healthy-looking ; tongue moist and clean ; pulse small, soft, weak ; no pain on pressure over the abdomen ; stools contain shreddy mucus and blood. Bismuth, ipecac, and soda, aa gr. v., three times a clay. March 7th. — Stools are greenish, foeculent, with a small trace of mucus and blood. By March 9th, the stools were free from any mucus and blood. The powder was omitted, and bael and koorchee mixture ordered, three times a day. The stools gradually became formed, and he was discharged on March 15th, 1880. Well in nine days ; duration of disease about twenty- three days. Case 4. — Acute Catarrhal Dysentery. K. D., Hindoo, a badly nourished boy, aged sixteen, was admitted into the Mayo Native Hospital, imder the care of Dr. Cayley, on September 23rd, 1880. Has been ill with looseness and fever for four days. Complains also of cough. On auscidtation, fine moist rales are audible at the base of the left lung ; skin harsh, dry, and hot; pulse feeble. ^. Spt. chloroform. 1)1. xv., mist, cretce §j. Diet, sago and milk. LECTURE II. 73 September 23rd. — 5 p.m. : Temperature 100° Fahr. Five stools since admission ; complains of griping. 24th. — Has had six stools in the night ; they contain shme and a good deal of greenish-jellow Kquid fseculent matter. Tormina and tenesmus excruciating. Temperature 98"2° Fahr. Ordered — IjL. Tinct. opii iTlx., aquse menth. pip. §j., stat. ; followed by — IJ. Pulv. ipecac, gr. xv. Diet, sago and milk. 5 p.m. : Temperature 98*4° Fahr. Vomited once ; passed four motions, containing mucus and blood, in tlie day. Griping and straining greatly diminished. I^. Ipecac. gr. iss. ; ext. bellad. gr. ^ ; pil. j. ter die. 25th. — Temperature 98*4° Fahr. Four stools in the night. The stools are composed of fseculent matter, with gelatinoid exudation only. Grriping and straining much less than before. Pills continued. Diet, sago and milk. 5 p.m. : Temperature 98'4° Fahr. Six motions, consisting of soft yellow foeculence with a little slime. Vomited once. 26th. — No stool ; no fever ; no griping and straining. Continued pills twice dally. 5 p.m.: Temperature 98'2° Fahr. One fseculent stool, containing very httle slime. 27th. — No stool ; no fever. Pills continued tmce daily. Diet, rice, fish, milk. 28th. — One healthy, well-formed stool. Pills omitted. I^. Acid, sulph. dil. iTiviij., inf. calumbae §j., ter die. 29th.— Doing weU. Discharged on October 1, 1880, in seven days. Case 5. — Acute Dysentery. Medical College Hospital, Calcutta ; Dr. McConnell. "William S., a Norwegian seaman, aged about forty, was admitted on July 10th, 1878, into Medical CoUege Hospital, having suffered from dysentery for four days — i.e., seven to eight stools in twenty-four hours, passed with much griping pain, and composed of blood and slime. He is weU-built and muscular, but has a worn and anxious expression. The tongue is moist, but much coated. 74 TKOPICAL DYSENTERY AM) DIAUKIKEA. The abdomen is retracted ; great pain on pressure over the right ihac fossa and along the course of tlie hirge intestine. No hepatic or splenic enlargement. Heart and lungs normal. The stools are very frequent, and consist principally of blood and rosy mucus ; they are passed with much griping and straining. From the 10th to the 14th his condition remained almost the same, the number of the stools decreasing ; somewhat less blood was passed, but rosy mucus still in abundance, and pain all over the abdomen severe. July 15th. — The character of the evacuations changed ; they were now watery and highly bilious, without a trace of either blood or mucus, but having a very offensive *' fishy " odour. The patient very weak and prostrated ; voice low and husky. This prostration gradually increased. On the morning of the 17th he was found quite collapsed ; the skin cold, covered with clammy perspii'ation, and over the hands and side of the thorax exhibiting numerous sudamma. Pulse imperceptible at the "svrist. He sank the same evening. Tempebatuees. 1880. Morning. Evening. 1880 Morning. Evening. July 10 .. ,, 11 .. „ 12 .. „ 13 .. 98-4° 98 4° 98-0° 100-0° 100-0° 99-0° 98-2° July 14 . . „ 15 .. ,, 16 .. „ 17 .. 99-0'' 98-6° 98-4° 97-2° 98-2° 980° 98-0° Treatment. — Cinchona alkaloid, pulv. ipecac, aa gr. v., ext. hyoscyami gr. v. — two pills ; tr. opii 1)1 xxv., aq. camph. §j.; followed by gr. xx. pulv. ipecac, in bolus; also opium suppositories, and latterly small enemata composed of pulv. ipecac, liq. opii sedativ., and mucilage. Post-mortem Examination (July 18th, 1878; about seventeen hours after death) . — Body moderately well nom-ished. The skin of the back, shoulders, and chest covered with sudamina and larger blebs, containing either serous or sanguineo-serous fluid, the latter of dark pTirplish colom-. An old cicatrix on the glans penis. Head : Brain a little softened and anfemic LECTURE II. 75 (Piueal gltind twice its normal size, and partially cj^stic) ; structure otherwise healthy. Thorax : Heart flabby and uncontracted. Right ca^dty contained fluid, dark blood, and small, dark, soft coagula. Similar but smaller clots in the left cavities. Aortic valves thickened ; the central flap has a calcareous nodule. The ascending aorta shows patches of syphilitic endo-aiieritis. Lungs : Anterior portion pale and emphysematous. Posteriorly and at the bases very dark, soft, and deeply congested. Abdomen : Liver large, weight 3 lbs. 10 ozs.), of dark red colour. The large portal and hepatic veins filled mth fluid blood (frothy from incipient decomposition) ; liver- substance generally soft ; lobular struc- ture indistinct. No reaction with iodine. Gall-bladder collapsed ; duct free ; bile thin, of turmeric-yellow coloiu", and measui-es only about a di-achm. Spleen a Httle enlarged, soft and dark, weight 7^ ozs. Kidneys somewhat darkly congested, like the other abdominal organs. The left, partially cystic at upper end. Nothing else remarkable, Alunentary canal : Stomach small and contracted, dark piuijlish in colour, and highly congested at the oesophageal end. The mucous membrane of the small intestine is bile- stained, in the duodenimi and jejunum. In the ileum, the patches of Peyer are a little prominent, and present the " shaved beard " appearance. The whole of the large intestine presents a thickened, swollen condition, the mucous membrane being in a state of sphacelus or acute slough. The sloughs are aiTanged more or less tranversely along the folds of the intestine ; they are of a greyish colour, highly putrid, the majority still adlierent to the adjacent tissues, some very loosely so, and others again, particularly in the rectum, have entirely separated, exposing raw red ulcers. The sub-mucous tissues, and even the muscidar coat in parts, are pus-infil- trated and very vascular. The mesenteric glands are a little enlarged and hypersemic. The stomach contains about four ounces of thin highly bilious fluid ; the small intestine about the same quantity of j'ellowish muco-fseculent fluid. The large gut is empty. TROPICAL DVSEXTERV AND ])1AKKIICEA. Case 6. — Acute Dysentery. Gr. D,, an East Indian, aged foi-ty-two, a compositor, was admitted on August 14th, 1880, into the Medical College Hospital, and died on August 28th. (Dr. McConnell.) History. — Has been suffering from irregular attacks of intermittent fever for the last three months. During the last three days the stools have become very loose and frequent. Is an opium eater, and is poorly nourished. The skin harsh and rough. Pupils a little contracted. Complains of pain all over the abdomen, which increases much when he goes to stool, and shoots down to the calves of his legs. The tongue is moist, but coated. No appetite. Heart's action regular ; pulse small. No enlargement of liver or spleen. The stools are seven or eight in the twenty- four houi's ; they consist of blood and gelatinous mucus, and are passed with much griping and straining. The temperature rises slightly in the evening (see chart below). The evacuations continued much the same, except that the blood lessened, and small sloughs came away, between August 18th and 20th. On the latter date improvement was noticed. Stools every four in the twenty-four hours, partly fseeulent, and containing only a little blood. The relief, however, was only temporary. On the 26th the motions increased in number (fourteen dm-ing the preceding twenty- four hours), and contained shreddy mucus with pus and blood. Troublesome hiccough now set in, and the patient became very low, his countenance anxious, and features simken ; the tongue dry and hard. On the 27th the stools were passed in his bed-clothes very frequently, and almost unconsciously. Hiccough still con- tinued. Yoice husky. Semi-delii'ious. Gradually sank and died on the 28th. LECTURE II. 77 Tempeeatuees. 1880. Morning. Evening. ISSO. Jlorning. Evening. Aug. 14 _ 98-4° Aug. 21 . . 98-6° 99-9° ,, 15 .. 98-4'' 99 0° ,, 22 .. — „ 16 .. 98-4= 100 0° ,, 23 .. 98-2° 102-6° „ 17 .. 98-C' 100 0° ,, 24 .. 100-8" 102-2' ,, 18 .. 98-6° 99 8° ,, 25 .. 101-6' 101-6° ,, 19 .. 98-6° 98 4° ,, 26 .. 100-2' 102-0° ,, 20 .. 98-0° 100-0° „ 27 .. 101-4° 98-8° Treatment. — Turpentine fomentations mth large poultices to abdomen. Tinct. opii nixv., spt. cMorof. nixxv., aquse menth. pip. §j. Sedative di'aught to be taken tki-ee times a day, ten minutes before the follomng powder, viz. : — Pulv. ij)eeac. gr. x., sodee bicarb., bismuthi nitrat., aa gr, v. Anodjme enema twice daily. Anti-si:)asmodics (musk, ether, etc.) for the hiccough. Changed on the 22nd to tinct. opii iilx., spt. sulph. aromat. iT^xv., ext. belse liquid. Sij-, decoct, koorchee §j. ( Wrightii (ndi-dijsenterica), four times a day. On the 24th, plimibi acetas gr. v., ext. opii gr. iss. in pil., four times a day. On the 26th, tinct. catechu 3ss., tinct. kino oSS., tinct. opii nix., decoct, hrematoxyli §j., four times a day. Lastly, hospital stimulant mixture, one ounce every two hours. Post-mortem Examination (August 28th, 1880 ; eight hours after death) . — Body emaciated ; rigor mortis strong in the lower extremities; none in the upper. Pupils dilated. Brain: Substance soft and ansemic ; otherwise normal. Thorax : Limgs congested ; their bases dark, heavy, and softened. Liver : Substance of dark muddy or slate colour ; is firm. Bile-ducts contracted ; gall-bladder full ; bile thick, fi'om the presence of much ropy mucus ; measm'es an ounce and a half. Weight of liver 2 lbs. 7 ozs. Spleen a Httle enlarged ; cap- sule slightly thickened ; substance soft and dark ; weight 9 ozs. Kidneys moderately contracted and distinctly " granidar " ; weight — right 3i ozs., left 4 ozs. Stomach of normal size ; mucous membrane pale and anaemic ; as also is that of the small intestine. That of the large gut is tlu'oughout thick and oodematous. From ctecum to anus, covered ■^ith small 78 TROPICAL DYSENTERY AND DIARRHfEA. superficial ulcers, of irregular outline, with much recent con- gestion and vascularity of the surrounding bowel, and the presence of a little recent exudation (lymph) over the surfaces and up the margins of these ulcers. The sub-mucous tissue in parts undermined and pus-infiltrated, everywhere much thickened, as also is the muscular coat. The post-peritoneal cellular tissue in connexion mth the ascending and descending colon is also thickened, and the lymph-glands are enlarged. Tlie mesenteric glands are a little swollen and oedematous. The stomach contains about half an ounce of ciu'dled milk ; the small intestine, about two ounces of soft bilious mueo- f eeculent material ; the large gut about an ounce of thin reddish serous fluid, with shreddy mucus and minute blood- coagula. Case 7. — Malarial Dysentery. M., a Hindoo boy, aged seven, native of Hoogly, admitted into the Mayo Hospital, under Dr. Cayley, on September 16th, 1880. He had been suffering from dysentery and prolapsus ani for four months. The child complained of much griping, and there was some fever ; he was much emaciated, and had enlarged spleen. In the evening the temperatiu-e rose to 102"8°. He had seven stools in the day, composed mainly of blood and a little slime. Spt. chlorof. in. v., with chalk mixture §ss., was given after admission, and a powder containing ferri carb. gr. iij., with. pulv. cinchona gr. ij., and pulv. cretse aromatic, gr. v., thrice a day ; and sago and milk diet. September 17th. — Had had nine stools, passing much un- digested milk and slime. Ordered a powder composed of ipecac, gr. j., Dover's powder gr. j., soda gr. iij., thrice; and liquor calcis was given "with the milk. Temperature 98*4°, but in the evening it rose to 102°. 18th. — Twelve stools in the night, composed of blood and slime, and the temperatm-e ranged from 99'2° to 101°. Two grains of quinine were added to each dose of the powder, and the same diet was continued. 19th. — There were onh^ three stools, vnih little slime and LECTURE II. 79 no blood. Temperature 99'6° in the evening. There was no fever. 20th. — There was slight fever ; temperatiu'e 99*2°. Seven stools in the day, with slime and blood, and four stools in the night, containing undigested milk and slime. A powder composed of ipecac, gr. j., comp. kino gr. iij., and bismuth gr. j., given thrice. 21st. — Three stools in the day, and seven in the night, with much undigested food and slime. The temperature ranged from 98"4° to 102"4° in the evening. The medicines were continued, and fomentation over the belly was ordered. 22nd. — Six stools, wiih. less slime than before, but more offensive, with sloughy-looking shreds of membrane ; tormina and tenesmus. In the night ten stools of similar character. Cold compress was aj^plied over the belly, and ice was given constantly to suck. Temperature ranging from 98'4° to 103°. 23rd. — Temperature 99*6° to 102"6°. Six stools in the day, \sith slime, but no blood ; and seven in the niglit. A mixtiu-e of iron alum, sulj^hm'ic acid, and opium was given four times, and arrowroot, milk, and ice for diet. 24th.— Temperatm^e 98*8° to 99-8°. Seven stools last night, and eight during the day ; again much blood and slime, attended with pain and straining and prolapse of the rectum. 25th. — No fever in the morning ; temperature 102*6° in the evening. Two stools only in the day, and twelve in the night, still composed of slime and blood. Dover's powder gr. iij., with comp. kino gr. ij., and ipecac, gr. j., given four times ; and an ounce of rum added to the former diet. 26th. — The stools passed were very offensive, watery, and of dirty brown colour. Evening temperatm-e 102°. An injection, composed of alimi gr. xv., tincture of opium iTl.x., and aquae 3vj., was given twice per rectum. 27th. — Three stools, with slime and blood. The tempera- ture ranged from 99° to 100°. 28th. — Two stools in bed-clothes, watery and offensive ; and three stools in the previous night. Temperature 97*6° to 101° Fahr. Patient becoming very low. 80 TROPICAL DYSENTERY AND DIARRHCEA. 29th.~Tlie temperatvire ranged from 98° to 101-8°, Constant stools passed in bed-clothes. Unable to swallow. Pulse imperceptible. Died at 10"30 in tbe night. This was an acute attack coming on in the course of old chronic dysentery in a child with enlarged spleen, and constitution broken do^vn by malaria. No post-mortem. Case 8. — Malarial Dy^sentery', Mayo Native Hospital, Calcutta ; Dr. Cayley. H., a Hindoo lad, aged eighteen, was admitted into the Hospital on August 12th, with sjonjitoms of acute dysentery. For ten days he had been suffering from remittent fever, and from the day previous to his admission had had frequent scanty evacuations of mucus and blood, with griping and straining at stool. On admission, the boy was found to be emaciated, with fulness of the belly, and an anxious expression of face, which was bedewed %\dth perspiration. There was fever. The spleen was enlarged, as also the left lobe of the liver. There was much tenderness of the abdomen, especially in the epigastriimi and over the spleen. In the evening his temperatui'e was found to be 103° Fahr. He had two scanty motions after admission, composed solely of mucus and blood, with no fascal matter. A ten-grain dose of Dover's powder was given at bedtime. During the night he had much griping with frequent stools, composed chiefly of blood. August 13th.— Temperatm-e 99° Fahi-. Ordered haK a grain of opimn, followed by twenty grains of ipecacuanha. In the day the stools continued the same, but were more frequent and the tormina and tenesmus aggravated ; he vomited three round worms. In the evening there was no fever, when a dose of santonin gr. iij., with soda gr. v., was given at bedtime. He passed a restless night, vv-itli incessant calls to stool. LECTURE IT. ^1 14tli. — A pill of ipecac, gr. ij. and ext. belladonna gr. ^ was given twice. No more worms were passed, and there was no fever. The temperature was 98'4°. The stools continued scanty and slimy, the tormina and tenesmus very severe. Evening : No fever. A dose of Dover's powder besides the pills was given. 15th. — About the same ; but the griping pain rather less severe. Instead of pills the following mixtiu-e was given : — Ferri sulph. gr. ij., alum, sulph. gr. v., acid sulph. dil. nix., and peppermint-water §j., three times a day, and fomentation for the abdomen. 16th. — Grriping increased ; stools remaining same ; no fever. The mixtiu"e omitted, and pills of ipecacuanha and belladonna again given. Evening temperature 101°. Issof- gool §88. was given at bedtime. 17th. — The stools became less frequent and of reddish- brown colour, consisting of blood and mucus and small coagvJa. Temperatm'e 98"6°. The same medicine continued, and cold compress over the belly was ordered. The patient was hitherto living upon sago and milk. In the evening there was slight fever ; temperature 100°. Ten minims of chlorodyne given at bedtime. 18th. — The stools were better ; with the slime and blood there was faecal matter ; tenesmus less severe ; tenderness over belly less. Temperature 98*2°. Instead of pills, issof- gool ~jj. [PJantago Isphagoola) twice a day ordered, and cold compress continued. In the evening temperature 100°, Rice and milk given for diet. 19th. — Temperature 98*2°. The stools were copious, but less frequent, consisting of slime, with vitiated bile and feecal matter, with streaks of blood. In the evening the temperatiu-e rose up to 101° Fahr. There were five stools throughout the day. 20th. — The patient was much in the same condition, the temperatiu-e ranging from 98*4° to 101° in the evening. Ipecac, gr. ij., opium gr. j., given thrice in the day, and continued for the next day. A little rice and fish were given, but he was again troubled with many stools in the night, com- 82 TROPICAL DYSEXTERY VXD DIARRIICEA. posed mainly of slime and undigested food, but no blood. The temperature ranged from 98"4° to 100'-i°. His diet was again changed to milk and bread, and the same medicine continued. 22nd. — Another scruple dose of ipecacuanha was given, after wliich he had eight stools, composed of slime, bihary and fiecal matter, with little blood ; griping less than before. Temperatm-e 98-2° to 102-4°. 23rd. — The patient still passed slime with little blood, but the tonnina much abated. The temperature ranged from 98'2°to 10r2°. Ipecacuanha and belladonna pills were given tlirice, and rice and milk for diet. 24th. — The stools became fieculent, with a Httle mucus. The patient now gradually improved, and his bowels became natui-al. The pills were changed to small doses of iron-alimi, and sidphmic acid with tinctm-e of opium, and a mustard- plaster was applied over the spleen, to allay pain. He was now given rice and milk diet, with addition of a Httle fish and rmn. 26th. — Liniment, iodin was painted over the spleen. September 13th. — After full diet, got an attack of diarrhoea, which was checked after two days by chalk mixture with chlorodyne. He was then given nitro-muiiatic acid with bark, and half rice and fish diet. 17th. — There was a retvu'n of fever, -^dth a temperature of 101° Fahr., and the following day five grains of quinine were given and haK an oimce of spleen mixtiu*e, composed of quinine gr. ij., acid. suljA. dil. tiix., ferri. sidjih. gr. ij., tinct. zingiberis nixx,, aqupe §j., given thi'ee times a day, and iodine liniment painted over the spleen and liver. 18th. — No fever. Evening temperatm-e 99'6° Fahr. After this there was no rise of temperature, nor any recun*ence of diaiThcea or dysentery. The jaatient was discharged cm^ed on September 22nd. Case 9.— Malarial Dysextery. P., a Mahomeclan male, aged nineteen, admitted into the Mayo Native Hospital on July 21st, 1880. He has been LECTTKE II. 83 suffering from fever, of continued type, for the last seven days. Complains of cough and pains all over his body. Bowels loose. On auscultation, breathing was found to be harsh and tubular in the back of chest. Temperatui'e 98'4° Fahr. Ordered tinct. opii ill v., spt. chloroform iilxx., mist. cretse co. §j., every four hours. Diet, sago and milk. 5 p.m.: Temperature 101 "4° Fahr. Had three motions in the day; the motions contained mucus and blood. 23rd. — 5 p.m. : Temperature 102*6° Fahr. No vomiting ; several stools in the day : they contain bloody mucus. Grriping less than in the morning. Ipecacuanha and belladonna pills continued. 24th. — Several scanty feeculent stools in the night; very Kttle slime. Temperature 98 '8° Fahr. 5 p.m. : Tempe- ratm'e 100*4° Fahr. Several scanty stools in the day ; the stools contain a little slime only. Dover's powder gr. X. h. s. 25th. — Several stools in the night ; the stools consisted of mucus and blood. Griping increased. Ordered tinct. opii I7i_xv., aqujB menth. pip. §j. ; followed by pulv. ipecac, gr. xx. 5 p.m. : Temperature 98*4° Fahr. No vomiting. Several stools in the day ; passed slime and blood. Griping excru- ciating. Infus. issofgool, pulv. Doverii gr. x. h. s. 26th. — Temperature 98*4° Fahr. Eight scanty fseculent stools in the night ; very little slime in the stools ; griping less than before. 1^. Ipecac, gr. j., opium gr. j., pil. j. ter die. Diet, half-rice, fish, milk. 5 p.m. : Temperature 98'4° Fahr. Five motions in the day, consisting of fsecident matter only, without slime and blood ; griping much less. 27th. — Is just the same. No griping. 5 p.m. : Two well- formed stools, without slime or blood ; no fever. 28th. — Doing well. From this date the patient never had any bad symptoms, excepting a recurrence of malarious fever, which was effectually checked by ten-grain doses of quinine. Discharged ciu'ed August 12th, 1880. G 2 84 TROPICAL DYSENTERY AND DIARRHQ-IA. Case 10. — Sloughing Dysentery, Kulterali K., a Maliomedan male, aged twentj-eigM, a labourer, was admitted into the Second Physician's Ward, Medical College Hospital, on April 8th, 1880, and discharged April 13th, 1880. History. — Stated that he had been suffering from dysentery for the last twelve days. Condition on Admission. — Is much emaciated ; eyes sunJien ; pulse small, weak ; tongue moist and furred. Had about ten or twelve stools, containing a large quantity of blood, flakes of mucus, and small bits of slough. No other complication. Subsequent Progress and Treatment. — On admission a dose of castor oil with tinct. of opium was ordered, and pulv. ipecac, co. gr. x. at bedtime, and bismuth and ipecac, powder tliree times a day. April 9th.— T-Stools five in nimiber, and contain shreds of mucus, deeply tinged with blood. Retained the powders. 10th.— Mucus and blood less than before. Stools less in number. 12th. — There is no mucus or blood in the stools. Stools half-formed and bilious. He took his discharge the next day. Native. Sloughing. Discharged after five days. Dura- tion of disease until discharged, about seventeen days. Case 11. —Sloughing Dysentery. K., a Maliomedan male, aged thirty-five, a coachman, was admitted into the Second Physician's "Ward, Medical College Hosjjital, on February 21st, 1880, and dischai'ged on February 28th, 1880. History. — Stated that he had been suffering from dysentery for the last twelve days. Passed several stools containing blood and mucus. Has had hiccough for the last five days. LECTURE 11. 85 Condition on Admission. — Is weak and much prostrated. Tongue moist and coated. Pulse small, soft, and weak. There is pain on pressure over the right hypochondriac region, as well as over the left iliac fossa. Stools several in number and very offensive ; contain small bits of sloughs and shreddy mucus deeply tinged with blood. No splenic enlargement. Is getting hiccough nearly every five minutes. Cannot sleep at night. One pint of congee-water enema on admission ; emplastrum sinapis over the diaphragm (its costal attach- ment) ; liq. opii sedativus 3j. and mucilage §j., an enema at bedtime ; and bismuth and ipecacuanha powder three times a day. February 22nd. — Hiccough continues. Stools very offen- sive, and contain sloughs, mucus, and blood. Tinct, moschi, spt. aether, and spt. chloroform mixture ordered every two hours. 23rd. — ^Hiccough is not so troublesome. Stools less in number ; mucus and sloughs and blood less. Opiate enema ordered twice daily. 24th. — Hiccough less. Three stools, containing bilious faeculent matter, with traces of mucus and blood ; no sloughs. 25th. — No mucus in the stools, which are bilious, soft, and foeculent. He improved in three days more, and took his discharge on the 28th. Native. Discharged in eight days. Duration of disease, twenty days. Case 12. — Sloughing Dysentery. G-., a native, aged forty- five, a clerk. Admitted May 27th, 1880, Medical College Hospital ; died on May 31st. (Dr. McConnell.) Has been subject to occasional attacks of looseness of the bowels, more especially dm-ing the past three months. Within the last few days (exact date not noticed) the disease has become truly dysenteric. The stools, seven or eight in 86 TROriCAL IJYSENTEllY AND DIARKHCEA. the twenty-four liom\s, are voided with much pain and tenesmus. Has been taking a good deal of opium lately (last two months) on account of the irritability of the bowels ; is weak and emaciated ; eonjunctivse muddy ; tongue moist and fm'red ; appetite lost ; complains of pain over the right side of the abdomen, along the whole com'se of the ascending colon, and on manipulation there is a feeling of resistance and hardness over this portion of the bowel, while the left flank is soft and comparatively free from tenderness ; no thoracic complication ; no enlargement of spleen or liver. After a small dose of oil guarded by tinct. opii, a few small rounded and hard scybala came away, with a little shreddy blood-tinged mucus. May 29th. — Stools very frequent ; contain much blood and shreddy mucus ; no sloughs. The tongue has become dry. The hardness and tenderness of the abdomen is un- relieved, and there has been bilious vomiting tliree times to-day. 30th. — Vomiting of dark, thin, bihous fluid continues. The stools are less frequent, but of the same character. 31st. — Is fast sinking. Evacuations serous and bloody, involuntary. Mind wandering ; apathetic. Died at 3 p.m. Treatment. — Fomentations and poultices over the abdo- men. Belladonna liniment applied over the course of the colon. Internally, — at first castor oil di'aught with opium, then ether mixtiu'e with tinct. opii : pulv. ipecac, in large doses ; finally, sinapisms to the epigastrium and diffusible stimulants. Post-mortem Examination (June 1st, 1880 ; eighteen hom'S after death). — Body emaciated and antemic. Rigor mortis slight in the lower extremities ; has passed off from the upper. Brain and membranes angemic. Heart feebly contracted. Fluid dark blood and large, yellowish, soft coagida in right cavities, and small similar clots in the left; valves healthy. Lungs pale and ansemic. Liver somewhat small ; substance ju-m ; of deep yellow colom- throughout, from uniform bile- staining. Bile-ducts dilated and filled with thick yello\v LECTUllK II. 87 secretion. Lobular structure indistinct ; seems ancemic. No reaction given with iodine. Grall-bladder about half full ; duct fi'ee. Bile very thick and of dark reddish-brown colour ; measures about half an ounce. Weight of liver two poimds twelve oimces. Spleen a Kttle enlarged ; substance soft and pulpy, of reddish-brown coloiu' ; weighs ten ounces and a half. Both kidneys somewhat atrophied, the renal substance yellowish fi'om bile-staining. Weight of right, three ounces and thi'ee- quarters, of left four oimces. Stomach of normal size ; mucous membrane sHghtly corrugated, throughout pale and anaemic. The mucous surface of the small intestine is pale and anaemic, except in the last two feet of the ileum, ^\here it is abnormally vascidar, injected, and marked by transverse bands or ridges of superficial ulceration, and invested by a thin granular layer or deposit of recent inflammatory exudation (lymph). The whole of the large gut is diseased. The caecimi, ascending and transverse colon show great thicken- ing of all the coats, ^^dth a sloughy condition of the mucous membrane. The sloughs are large, greyish or tawny, easily detached from the sub-mucous tissues. In parts where they have thus become already detached, deep transversely placed ulcers are exposed, reaching to the muscular, and in some parts almost to the peritoneal coat. In the former case, the muscidar tissue exposed is soft, shreddy, and pus-infiltrated ; while the margins of the ulcers are thickened by the deposit of recent granular lymph. In the descending colon, sigmoid flexm-e, and rectum, these changes are not so marked ; but the muscular coat and post-peritoneal cellular tissue belonging to and smTOimding this portion of the gut, present a highly thickened condition. The mesenteric glands are enlarged, and on section found soft, swollen, and hj'percemic. The stomach contains half a pint of thin broA\'nish fluid, with a good deal of partially coagulated milk ; the small intestine about f om^ oimces of thin brownish-yellow faeculent fluid, with a large number of small, chy, and hard scybala ; the large gut only half an ounce of brownish semi-solid faeculent matter, and slu'eds of detached sloughs. 88 TROPICAL DYSENTERY AND D1ARRH(EA, Case 13. — Suppurative Dysentery, (Dr. Cayley.) 0., a resident of NinetoUah, aged tliii'ty, admitted into the Mayo Native Hospital on August ITth, 1880. States that he has been suffering from sjonptoms of dysen- tery during the last ten days. About twelve days ago he had an attack of fever, two days after which he noticed bowel complaint. Daily he passed many stools, attended with much griping and straining. The stools contain chiefly slime. There is much tenesmus and griping. Tongue moist, but furred. On admission, the temperature was 100'4° Fahr. I^. Tinct. opii nixv., aquse menth. pip. §j. 1^. Pulv. ipecac, gr. xx., half an hour after the above. Diet, sago and milk. 5 p.m.: Temperature 103° Fahr. No vomiting. Has had six stools since morning ; the stools are f eeculent, but contain abundance of slime, without blood. Griping much less than the morning. 1^. Pulv. ipecac, gr. ij., ext. bellad. gr. J, misce; ft. pil. j. t. d. August 18th. — Temperature 100'4° Fahr. No vomiting. Five stools in the night ; the stools are scanty, and contain gelatinoid exudation. 5 p.m. : Temperature 103° Fahr. Seven scanty stools in the day. Grriping and tenesmus just the same as before. Ipecacuanha and belladonna pills continued. Turpentine stupes and fomentation over the abdomen. 19th. — Temperature 101*G° Fahr. Seven stools in the night ; the stools contain slime and bihous secretions. Tongue fmTcd. Ijt. Tinct. opii I7\xv., aquoe menth. lAip. §j. l\^. Pulv. ipecac, gr. xx., half an hoiu" after the above. Cold compress over the abdomen appKed. 5 p.m. : Temperature 102*4° Fahr. Five motions since morning, composed of soft yellow f seculence, with several portions of gelatinous exudation. There is pain and tenderness around the navel. Tongue coated in the centre. Griping distresses him much. No vomiting. 1^. Ipecac, gr. ij., ext. bellad. gr. |, pil. j. ter die. Cold compress continued over the abdomen. 1^. Pulv. Doveri gr. v. h. s. Diet, sago and milk. '2()tli. — Temperatm-e 102*4° Fahr. Countenance depressed i. ' ACUTE DYSENTERY WITH MULTIPLE ABSCESSE.S(/Vf|/'f7r/c R/irc«f,9) OF LIVER CASE 14 PACE S'' LECTURE II. 89 and anxious; pulse feeble; tongue furred. Seven evacuations, composed of a small quantity of liquid faeces, undigested milk, and much gelatinoid exudation, mixed up with shreddy sloughs. Ijt. Ipecac, gr. ij., ext. opii gr. ss., pil. j. ter die. Cold compress continued. Diet, aiTOwroot and milk. Eum gij. 5 p.m. : Temperatm-e 103"4° Fahr. Seven stools in the day ; the stools are mainly purulent. ^. Pulv. ipecac, co. gr. x. h. s. 21st. — Temperature 100-8° Fahr. The patient is much prostrated. Passes stools in bed, which are like pus, and of liighly offensive odour. Pulse feeble. 1^. Acid, carbolic, gr. j., opium gr. j., ter die. Diet, arrowroot and milk. Eimi §iv. 5 p.m. : Temperature 102° Fahr. Several copious purulent stools in the day, of highly offensive odour. Pulse very feeble ; voice low and husky. Griping distresses him much. Ijt. Plumbi acetas gr. ij., ext. opii gr. ss., pil. j. h. s. 22nd. — Temperature 98"-l° Fahr. Several firm but offen- sive stools in the bed-clothes. Pulse scarcely perceptible at the wrist. Body cold, bathed with clammy perspiration. Symptoms of collapse set in. Died about 8 a.m. of the same day. Post-mortem Examination — Peritonemn of normal hue ; no fluid in its cavity. Intestines more or less congested. The whole of the mucous membrane of the lower half of the ileum and large intestine was in an advanced state of inflam- mation, being of an uniformly pale rose-red colour, denuded of epithehum and covered with offensive, unhealthy pus. There were a few dysenteric ulcers near the ileo-csecal valve. Nothing very particular with other viscera, except that the kidneys were enlarged. Case 14. — Acute Dysentery and Liver-Abscess. This case is the one represented in the drawing in the frontispiece. Medical College Hospital, Calcutta. G., a Hindoo, aged twenty-four, achnitted August 7th, 1880 ; died August IGth, 188o! 'UNOEP K»*' ACUTE DYS ],ECTURE II. 89 and anxious; pulse feeble; tongue furred. Seven evacuations, composed of a small quantity of liquid fseces, undigested milk, and much gelatinoid exudation, mixed up with shreddy sloughs. IJt. Ipecac, gr. ij., ext. opii gr. ss., pil. j. ter die. Cold compress continued. Diet, arrowroot and milk. Eimi§ij. 5 p.m.: Temperature 103*4° Fahr. Seven stools in the day ; the stools are mainly purulent. IjL. Pulv. ipecac, co. gr. x. h. s. 21st. — Temperature 100-8° Fahr. The patient is much prostrated. Passes stools in bed, which are like pus, and of highly offensive odoiu". Pulse feeble. ^. Acid, carbolic, gr. j., opium gr. j., ter die. Diet, arrowroot and milk. Rimi §iv. 5 p.m. : Temperatm-e 102° Fahr. Several copious punilent stools in the day, of highly offensive odour. Pulse very feeble ; voice low and husky. Griping distresses him much. I^t. Plumbi acetas gr. ij., ext. opii gr. ss., pil. j. h. s. 22nd. — Temperature 98'4° Fahr. Several firm but offen- sive stools in the bed-clothes. Pulse scarcely perceptible at the wrist. Body cold, bathed with clammy perspiration. Symptoms of collapse set in. Died about 8 a.m. of the same day. PoHt-mortein Examination — Peritonemn of normal hue ; no lluid in its cavity. Intestines more or less congested. The whole of the mucous membrane of the lower half of the ileiun and large intestine was in an advanced state of inflam- mation, being of an uniformly pale rose-red colour, denuded of epithelium and covered with offensive, unhealthy pus. There were a few dysenteric ulcers near the ileo-csecal valve. Nothing very particular with other viscera, except that the kidneys were enlarged. Case 14. — Acute Dysentery and Liver-Abscess. This case is the one represented in the drawing in the fi'ontispiece. Medical College Hospital, Calcutta. Gr., a Hindoo, aged twenty-four, admitted August 7th, 1880 ; died August IGth, 188o! 00 TROPICA], DYSENTERY AND DIARKIHKA. Had diarrhoea for a month, cvilminating in dysentery with fever during the last seven days ; is weak and anxious- looking. Great pain over lower part of abdomen, which is hard and tender to the touch, especially at one spot, about tkree inches below the right costal arch, in the com'se of the ascending colon, where also a distinct tumour-like thickening of the bowel can be felt almost the size of the closed fist. It is dull on percussion. The stools are very frequent ; ten to twelve in twenty- four hours, and passed with much griping and straining. They consist of soft fa3culence, with branny mucus and blood. August 8th. — Thirteen stools in last twenty-foiu* hom's ; abdominal tenderness increasing ; urine scanty. Temperature 100° Fahr. 9th. — Several dark sloughs passed to-day, and the timiom-- like swelling in the abdomen is diminishing. 12th. — Seven to eight stools in twenty- foiu- hours ; no more sloughs ; a little feecidence and blood. 14th. — Patient weak ; fever increasing. Twelve stools to- day ; fseculent and bilious. loth. — To-day the stools contained a few more pieces of slough and gelatinous mucus ; nine stools during the night ; pain in abdomen much less. Evening : Has had ten evacua- tions during the day ; countenance very worn and anxious ; pulse small and weak ; extremities cold. The tumour has entirely subsided ; gm-gling on pressm-e in the right iliac fossa. 16th. — Sub-normal temperature 9G*4° to 97°; pulse thready. Twelve stools dming the day ; contained sloughs. Body bathed in sweat. Sank gradually, and died at 8"45 p.m. Tempeeattjees. LECTURE II. 91 Treatment. — Piilv. ipecac, sod. bicarb., bismuth., aa gr. v. ter die. Anodjoie enema bis die. Equal parts of iodine and belladonna liniment rubbed over thickened bowel ; hot fomentations over abdomen. The ipecacuanha was replaced by Dover's powder after a day or two ; then acetate of lead gr. v., opii gr. j., in pil. ; lastl}^, diffusible stimulants. Post-viorton Examination (August 17th, 1880 ; twelve hom's after death). — Body emaciated ; rigor mortis slight. Brain- substance pale, anaemic, much softened. Lungs : Anterior portions pale and anaemic ; but the margins and bases dark and congested ; the lower lobes oedematous. Heai-t feebly contracted ; fluid dark blood with small fibrinous clots in right cavities ; a little fluid blood in the left ; muscular tissue pale and soft. Abdomen : Small intestines much distended with flatus, their walls unusually thin and translucent. The transverse colon is seen glued to the under sm-face of the liver by a little recent lymph. There are similar soft recent adhesions betv/een the Hver and diaphragm and between the transverse colon and duodenum ; and about two oimces of opaque turbid serum effused into the general peritoneal cavity. Liver of about noiinal size ; weight 2 lbs. 15J ozs. Both upper and lower surfaces are covered with soft projecting nodides, seen on section to be abscesses. They vary in size fi'om a hen's e^^ to a hazel-nut, and on incising the hver are seen also thickly distributed thi'oughout the parenehjona of both lobes. Each abscess is distinctly circumscribed, is surrounded by a bright hjqiersemic zone, and contains a varjdng quantity, from a few drops to half an ounce, of thick, giaiiy, greenish-yellow pus. Such portions of the liver-substance as remain unaffected are soft and greasy. The lobular structm-e indistinct. No reaction imder iodine. Gall-bladder about a third full ; duct free ; bile thick, reddish-yellow ; measures a httle over two di-achms. Spleen a little enlarged. Capsule much tliickened and opaque ; adherent to the surroimding parts. Substance moderately firm. The trabecular structm-e thi'oughout much hypei-trophied. Weight 7f ozs. A good deal pigmented at the periphery. Kidneys a little congested ; notliing else 92 TROPICAL DYSENTERY AiND D1ARRH(EA, remarkable. Stomach small and contracted. The mucous membrane a good deal congested, pale, and ansemic. That of the small intestine also pale and ansemic, but stained yellow from bile. The ileum tlu-oughout is much thinned. The ileo-csecal valve has been partially destroyed by ulceration. The whole of the ctecmn presents a thickened, puckered, and ulcerated condition. The mucous membrane of the rest of the large intestine is highly swollen and oedematous. A little below the hepatic flexm-e of the colon is a very large trans- versely placed ulcer, its margins covered with recent creamy inflammatory exudation (lymph) ; and the rest of the gut is thickly covered by transversely placed ulcers and sloughs, the majority also showing a granular recent deiJosit of Ijonph at their margins and bases. The sub-mucous and muscular coats of the bowel are enormously swollen and oedematous, very much thickened over the whole ascending colon, and especially rigid in the neighboui-hood of the large ulcer therein found above described. The whole intestine is contracted in calibre, abnormally firm, rigid, and shortened. The mesenteric glands are not affected. The stomach con- tains about two ounces of milky fluid ; the small intestine about six ounces of brownish, thin, muco-foeculent fluid ; the large gut about half an ounce of thin, highly offensive fseculence, -with one large dark slough and numerous small fragments or shreds of others. I am indebted to Mr. Alban Doran, of the Royal College of Surgeons, for the following report on the micro- scopic examination of the so-called abscesses of the liver of this case : — " I selected a small piece of hepatic tissue, close to the sm-face of the liver, which included a spherical white limip, Ann throughout. The liver-substance aroimd it was of the normal colour and appearance ; the sm-face was slightly puckered over the white liunp. " Sections of this piece were cut, after hardening, by Dr. Vincent Harris, in the Physiological Laboratory of St. Bartholomew's Hospital ; the freezing microtome was used for this pm'pose. The section here shown was stained with lk(;ttire II. m logwood. I then examined this section, and found the following appearances : — " In the midst of the white mass (Fig. 1) I distinguished a cloudy or faintly granular matrix, containing a few liver- cells, some with their outlines tolerably distinct {a), others much broken do"\vn {b) ; so that I suspect the granular matrix may be made up of debris of liA^er-cells. More dis- tinct than these cells were elongated bodies (c), of the shape of cells seen in young connective tissue, only none were so o- -I ■s ^f\^ distinct. I could not detect a nucleus in any ; and when seen in a mass, under a low power (Fig. 3), they had a fibrillated appearance. The exact nature of these bodies is uncertain ; they possibly represent fibrillation of new con- nective tissue, or may have been artificially produced by the action of the hardening mediimi on the not quite absorbed fluid part of an old abscess. The portions of the section which included the border of the white mass showed the fibre-like or spindle-cell like bodies very indistinctly (Fig. 2), 04 TROPICAL DYSENTERY AND THARRIin.A. large and perfect liver-cells Ui) predominating, whilst some of these were undergoing degeneration (/>). The appearance of the section at the extreme limit of the white mass, and close to the most evidently normal pai-t of the true liver-sub- stance (Fig. 4, a a a), shows the morbid change {h c, same as in Figs. 1, 2, and 3) in a still earlier condition. "It is at least clear that the morbid action has taken place amidst the true liver-cells, and never displaced them, but simply destroyed them in their places, for the debris of these cells may be distinctly traced in the deepest part of the white mass. They appear, in fact, to have broken do^voi from acute local inflammation ; the cells (i^. Figs. 1 and 2) being homologous to the ' cloudy ' and swollen cells in tubal nephritis. No true leucocytes can be found, hence exudation from the vessels must have been very slight." The following cases at the Campbell Hospital, Calcutta, were under the care of Surgeon Khan Bahadoor Tameez Khan, Physician to the Hospital. Case 15. — Acute Sloughing Dy^sentery, complicated WITH Enlarged Liver and Spleen. N., aged thirty, a Bengalee Hindoo, admitted Septem- ber 15th, in the First Medical Ward of the Campbell Hospital, with symptoms of dysentery. Patient, a fisherman, resident of Chingree Grhatta, a most unhealthy locality, exposed to constant malarious exhalations of the salt-water marshes to the south-eastern end of Calcutta. He is a dissolute-looking, weak-oonstitutioned, and emaciated person, very intemperate ; is in the habit of drinking country liquor (arrack), and eating decomposed salt fish. In consequence of ii^regular habits and intemperance, he has been subject to occasional attacks of dyspepsia, with acidity, flatulence, nausea or vomiting, followed by looseness of the bowels. He has also suffered from repeated attacks of malarious fever, and has a greatly enlarged spleen. About a month and n half ago. LECTURE 11. 95 having indulged too freely in salted fish, and di'unk too much " arrack," he placed himself under a koberaji's (native doctor's) treatment. Obtaining no relief, and finding he was suffering fi'om dysentery, he came into hospital. Was then having from six to eight motions in twenty-four hoiu-s, attended with much tormina, but no tenesmus. The motions were liquid and fieculent, but contained no blood or mucus. In the left limibar region and left iliac fossa there was intense pain, aggravated on pressm-e. No signs of febrile disturbance. Pulse small, weak, and frequent ; tongue clean and reddish ; had no appetite ; much nausea ; micturition not difficult. Was ordered castor oil oiv., laudanum 5 drops, peppermint- water §ss. — draught. Diet, milk and rice. September 17th. — Had many dejections containing mucus and blood, but no fsecal matter. Pain and hardness in the left, iliac and lumbar regions have much increased, and render him unable to strain. Had no fever. I^. Dover's powder gr. v., ipecac, powder gr. iij., bismuth gr. v., and gmn acacise powder gr. v. — to be made a powder, to be given thrice a day. Frequent linseed-meal poultices over the seat of pain. Diet, milk and rice. 18th. — Has had a great many stools in the last twenty-four hours, consisting of copious darlc reddish-looldng fluid, in which were found floating small masses of dark-greenish and brown frothy fceculent matter. No fever. Pulse small and weak. Pain much the same. Complains of griping, but no straining. Same medicine and diet. 19th and 20th. — Calls to stool increasing in frequency — ten or twelve in twenty-four hours. The stools consist of small quantities of greenish-yellow fseculent matter, with copious blood and mucus. No fever. Pulse weaker. Has hiccough. Is seen Ijing frequently on his left side, with his hand pressed over the left side of his abdomen. Tormina but no tenesnms at stool. Same medicine. Opimn enema. Milk and bread for diet. 21st. — Many stools since last report. Passes a quantity of dark-reddish fluid, but no fasculent matter. Stools being washed, large masses of dark blood-clots, as well as inuumerable 9() TROPICAL DYSKXTKRY AND DIARRHQ'.A. red-stained branny slouglis and some gelatinous mucus, were seen. Has been very restless and sleepless. Countenance anxious and pincbed. Has vomited once. Hiccough very troublesome. No febrile reaction. Pulse very small and Aveak, Tongue dryish and covered with a brownish fur. Has passed urine freely. Abdominal pain continues, but has felt easier since the opiate injections were given. Continued the medicine and opium injections. Acetate of lead gr. x. in each injection. Poidtices over abdomen. Milk and bread ; rum two ounces. 22nd. — Worse and very weak. Had many stools consisting of a copious reddish fluid, highly offensive, with a little yellow ffecal matter. On washing, clots of blood with grey- coloured shreddy sloughs in abundance were found. Pain in the left iliac fossa and left limibar region is severe. A cylindrical hard mass is perceptible. No febrile reaction. Pulse very weak and low. Vomited once ; hiccough trouble- some ; had very little sleep. Takes no nourishment. Omit ipecac. Continue the injections and poultices. Rmn 3iv., aromat. spt. ammon. i)i.xx., decoct, of koorchee §ss., e\ery six hours. 23rd. — Is quite prostrated ; countenance pinched and shrunken. Had no fever. Had only two motions within last twenty-four hours, but the pan contains more than four pints of dark-reddish thin liquid, of a highly putrid odour. On washing, large clots of dark grmnous blood, with nimierous fragments of black slough, were found. Sm-face cold and clammy. Pulse excessively small and thready. Abdominal pain hardly complained of, but patient shrinks when pressed in the left iliac fossa, where hardness is still perceptible. The same stimulant, enemata, and poultices were ordered to be continued. Was also ordered to have gallic acid gr. viij., dil. sulph. acid nix., liq. opii sed. nivij., decoct, koorchee 3ss., every six houi"s, with the stimulant and diet as before. 24th. — Temperatiire 98"4° ; pulse 46 ; respirations 19. Said to have had only four motions in last twenty-four hours, consisting of dark, grumous, sanguinolent liquid, wliieh on washing was found to contain clots of blood and LECTURE II. 97 many pieces of dark charred slough of a highly offensive odour. There is griping as well as straining ; the pain in the left iliac and lumbar regions is less ; pulse very small and thready ; vomited once ; hiccoughs occasionally. For the first time since admission patient is reported last evening to have had a slight febiile accession. Temperature 99'4°. 25th. — Last evening, again, there was some febrile dis- tm'bance — temperature 99'4°, but this morning it is normal ; pulse excessively weak, small, and thready ; tongue moist and clean ; a cadaveric odoui' is exhaled from his body. Twice moved only during the last twenty-four hours ; motions con- sisting of thin, dark, grumous blood, no clots, but black sloughs were foimd in the bottom of the pan ; abdominal pain mucli the same ; the hard swelling in the left iliac fossa gives a dull sound on percussion, and continues to be very painful. Has been very restless, had no sleep ; hiccough incessant ; no vomiting ; took very little nourishment. Medi- cine continued. Diet, milk two pints, nun two ounces, 26th. — Is worse. Last evening the temperature was 99°, but this morning it is rather below normal. Had no sleep, and was very restless all night ; has passed several scanty, highly offensive, and dark chocolate-coloured motions in bed ; hiccough incessant ; refuses medicine and food ; pulse flutter- ing. A small draught composed of some tincture of bella- donna and chloric ether was given to relieve the urgency of the hiccough — to no purpose. Tongue dry and brown. Turpentine stupes. Diet same. 27th — Patient is in a state of unconsciousness. Skin cold and covered with clammy sweats ; pulse barely perceptible ; has passed several motions in the bed-clothes, which are stained of a dark-reddish and greenish colom-, highly foetid. To have nun and milk occasionally, and stimidants. Died at about 1 a.m. of the morning of September 28th. Post-mortem Examination. — Body much emaciated; no rigor mortis present. Head not examined. Chest : Both the lungs were firmly adherent to the thoracic walls by old and film fibrinous bands. On section, the lung-substance appeared to be of a dusky reddish colour, and non-crepitant. 98 IKOl'lCAl, DVSl'.N TKIiV AM) DIAHRHfEA. The lower lobe of tke left limg, on its posterior aspect, was much congested, and of a bluish- red colour ; section firm and non-crepitant. Bronchial tubes empty ; their lining mem- brane pale. No pericardiac effusion. Heart small and atrophied. Both the right and left ventricles contained softish decolorized clots ; that on the right side was seen to be prolonged into the interior of the larger-sized branches of the pulmonary artery. Valves and endocardium apparently healthy. Abdomen : In the right side of the abdommal cavity a small quantity of serous exudation was present. Liver much enlarged ; a portion of the anterior edge of the right lobe was found adhering to the upper portion of cpecum, and the left lobe was adherent to the spleen below and the diaphragm above. Just towards the anterior edge and upper surface of the liver, and located just above the fundus of the gall-bladder, a perfectly white and sacular swelling of about the size and form of a hen's egg was seen. The walls of the sac were traversed by fine red blood-vessels. On opening the sac, about three or four drachms of a curdy, yellowish piu'ulent matter, precisely similar in colour and consistence to the matter from strumous abscesses, issued. The inner wall of this small abscess was lined by a small and even membrane. Liver capsule somewhat thickened and opaque. Liver parenchyma somewhat coarse, granular, and softish, and of a pale red colom\ Within the portal vein, fi'om its commencement in the transverse fissiu^e to about three or four inches within the hepatic parenchyma, a large dark clot of blood was found ; gall-bladder was fuU of apparently healthy bile. Spleen considerably enlarged and extensively adherent to the diaphragm, to the left lobe of liver, to left kidney, to the splenic flexm-e of colon, and to portions of omentum. Its capsule was densely thick, white, and of a semi-cartilaginous consistence. Its parenchymatous structure soft, and of dark grumous colour. Kidneys appeared to be congested. The lower third of the small intestine was in a congested state ; particidarly the portion of ileum near the csecum. Many of the coils of the small intestine were adherent to each other, and above to the transverse colon. l.ECriKE Tl. 99 The large intestines were much dilated, and their coats, particularly those of the csecum, considerably thickened. It has already been noticed that a portion of the lower anterior edge of the liver was adherent to the csecum. The latter, immensely thickened, was adherent anteriorly mth the abdominal walls, behind to the iliac fossa and psoas and iliacus muscles. The hepatic flexui'e of colon was firmly adherent to the under surface of the liver ; its transverse portion to the stomach and pancreas behind ; its left cm-ve was adlierent A\ith the spleen. The jejunrun was adherent to the transverse colon, a spot of which was found about to open into the adherent small gut ; the spot was covered with a layer of soft yellow IjTnph. The lowest portion of the descending colon, and the upper part of the sigmoid flexure, were also in a similar condition, and had just escaped perforation. The vermiform appendix had a dark and charred appearance, was t"«dsted upon itself, and was ad- herent to the dilated portion of the csecum. On laj'ing open the large intestines, the whole of the internal sui-face was a mass of ragged, disintegrated, charred, and black debris of slough. In most places not the slightest vestige of the mucous or muscular coats was to be seen. Here and there whole portions of these coats were left behind in the wTCck. There, and beneath them, and between the still intact serous coat, quantities of dark-coloured, sanious, and highly putrescent diffluent substance was seen to infiltrate and burrow underneath the coats to some distance. The inner coats of the large intestines were so completely destroyed by gangrene, that nowhere coidd any definite outline of ulcers be seen. The vermiform appendix presented the same black and charred appearance in its interior. The ileo-csecal valve was also involved in the gangrenous process. A few circular scooped-out ulcers were met with within a few inches of the termination of the ileimi. The mucous coat of both the stomach and duodenum was much congested and softened. 100 TROPICAL DYSENTERY AND DIARRHtEA. Case 16. — Sloughing Dysentery, with Discharge of a Very Large "Tubular Slough " — Complete Eecovery. Campbell Hospital ; under the care of Khan Bahadoor Tameez Khan. S. K., an Afghan, a native of Cahool, aged about fifty- eight years, a petty dealer in clothing, etc., came to Calcutta in November, 1879. He has been constantly exposed to vicissitudes of temperature, and has slept in the open verandah of a very damp house. His food has been poor, and the drinking-water in the locality where he resided was not good. Being an orthodox Mahomedan, he has never taken spirits or any intoxicating di'ug. A fortnight before admission he had an attack of malarious fever, of a quotidian type, contracted in Burdwan. This compelled him to quit that place and come down to Calcutta. Prior to admission, he was suffering also from constipation, for which he took an aperient, with little effect. The same evening he ate heartily of beef and wheaten cakes. During the night succeeding he suffered from griping pain in the abdomen. The next day, to clear his bowels, he took another aperient, and again in the evening indidged in food. Since then (eight days ago) he has been suffering from dysenteric s}Tnptoms. He appears to be weak, but is a wiry, thin- built elderly man. Has very frequent and scanty motions, consisting of blood and mucus, without fteculent matter. There is much griping and straining, and severe pain in the left ihac region. Micturition is difficult. He has daily paroxysms of fever from about 2 p.m., which last fourteen or fifteen houi's, intermitting at 4 a.m. Countenance anxious ; tongue clean and moist. There is nausea, but no vomiting. Has no appetite. Pulse soft and small ; tem- peratiu'e not taken. Has neither pain nor fidness in right hypochondriimi. To have j). ipecac, gr. v., p. ipecac, co. gr. iij., bismuth gr, v., p. gum acacise gr. v. — one powder every eight hours. AnodjTie injections twice a day. Diet, milk and rice. September 6th. — Two of the three doses of medicine given LECTURE II. 101 were rejected. Patient felt much relieved since he had the injections and powders, and slept better than he had done lately. In the motions some small masses of faeculent matter were noticed in the dejecta. Had the febrile paroxysm as usual. Upon the whole he feels better, but is very weak. Continued medicines. Diet, spoon; milk two pints, rmn two ounces. 7th. — Is worse and very low. Had many motions, which are quite liquid and of a reddish meat-washing colour ; mucus and much clotted blood. Griping and straining severe. Pain in anus is also complained of. Fever came on about 10 a.m., with rigors and chills, and left at 2 p.m., with sweating. Tongue dry and clean. Has vomited twice. No appetite. Pulse very weak. Same medicine, same diet. 8th. — Much the same as on last report. Febrile paroxysm as usual. Had from twelve to fourteen motions of the same nature as last reported, but they again contain some yellowish fsecal matter. Has much straining and pain in anus ; griping pains are complained of in abdomen also ; difficulty in micturating continuing as before. Was not so restless last night, and had some sleep. Appetite better. Continue the medicine. Turpentine stupes over abdomen. 9th. — Fever came as usual. Had twenty motions during the last twenty-four hours — thin ; colour and consistence as above noted. He is weaker. Medicines and diet continued. 10th. — Fever less ; lasted about four hours only. He looks better. Had about twelve or thirteen stools in the last twenty-four hours ; not copious, consisting of brownish, semi-hquid, fseculent matter, without any traces of blood or mucus. Grriping less, but straining and pain in anus continue. Has no difficulty in passing water now. Pulse very weak and feeble. Less pain in the left iliac fossa. Inclined to eat a little. Looks cheerful, but is very weak. Omit ipecac. Grallic acid gr. v., cinchona alkaloid gr. iij., dilute sulph. acid gr. x., liq. opii sed. nivj., rum 5ij., decoct, koorchee 5ij. — mist., make a draught — once every thi'ee hours. Continue opiate enema and tuqjentine stupes. Spoon diet ; milk two pints, rum two oimces. 102 TROl'lCAI, DYSENTERY AND DIAKRIICEA. 11th. — Had no fever dming the last twenty-foui' liours. Had twenty- four grains of the cinchona alkaloid. Frequency of calls to stool increased, but in character and consistence stools same as last reported. A long tubular dark grey coloured slough is seen protruding out of the anal orifice. It is highly offensive, and seems to be still firmly attached above. Patient is very low ; pulse very small and quick ; skin cold, covered with clammy sweat. Towards the evening had slight febrile reaction. Continue same medicine ; same diet. 12th. — Nmnber of motions passed during the last twenty- four hours much less (only five) ; they are of a thick syrupy consistence, and of a greenish-yellow colour. On the surface some pitrulent matter is observed ; no blood or mucus seen. The protruding mass of slough has not separated, but, owing to constant straining, it has protruded more, and is about a foot long ; looks of a dark grey colour, and emits a highly putrid, gangrenous odour. On washing the stools, another small shreddy and jagged black-coloured slough was found in the bottom of the pan. Temperature normal ; skin cooler ; pulse feeble ; no pain in iliac region. No hiccough or vomit- ing. Tongue moist and clean. Appetite better. Continue medicine. Milk and bread diet ; mutton broth ; nun. 13th. — Had slight fever last evening for about three hours, which has left with sweating. At present, temperature normal. The protruding slough has separated. He looks easy and comfortable. Abdomen soft and retracted, fi-ee from pain. Had seven stools during the last twenty-four hours. Motions fseculent, some of an ochrey-yellow colour ; no traces of blood or mucus to be observed. Pulse small, soft, and steady. Tongue clean and moist. A peculiar fishy odom' is exhaled from his person. Continue medicines. Body to be sponged with tepid water and Condy's fluid. Diet same. 14th. — Much the same as yesterday. 15th. — Had slight pain. Bowels moved ten times. Motions more consistent, foeculent, and of a yellowish-di^ab colour. On washing the dejections, a jagged, irregular slough, about three inches long, quite tubular, of smaller diameter than the LECTLRE II. 103 first, was found amongst the f seculent mass. Has no griping, straining, or pain in abdomen ; no hiceougli ; no pain about tbe anus. Appetite very good. Continue medicines. Omit opium enemata ; substitute opium suppositories. Diet, milk and bread twice a day ; extra milk one pint, rimi two ounces. 16th. — Had slight fever last evening. Bowels moved eight times during the last twenty-four hours ; dejections fsecident and pultaceous, of a yellow colour ; no traces of blood, mucus, or sloughs to be seen. Says he feels pain in anus, and has a throbbing sensation within abdomen, just about the umbihcus. Pulse soft and steady. Tongue moist and clean. Appetite good. Slept well. The same medicines and diet. 18th. — Much the same as reported last ; but the niimber of fseculent and pultaceous motions seems to be increasing. Has a voracious appetite ; is continually asking for more food. The same medicines, with gaUic acid two grains, and Hq. opii sed. two drops, in addition, in each dose. Diet the same. 19th. — Had twelve motions since last report ; colour and consistence much the same as reported before, but the two stools he had last appear to have a coating of yellowish pui'ulent matter over their outer sui'face — piu'ulent matter, but mixed mth foeces. Has no griping or straining ; no pain on pressm-e anywhere on abdomen ; no pain or uneasiness in right hypochondrimn ; feels very comfortable and easy ; appetite very good. Same medicines ; the same diet, with extra amoimt of soup. 20th to 23rd. — Patient has been gradually and steadily improving. His appetite is excessive ; he is not satisfied with the quantity of food he gets. Has been having from seven to ten motions in the day, but they are becoming more consistent, fseculent, of a yellowish colour, and do not contain any blood, mucus, or sloughs, but occasionally a few drops of purulent matter is to be seen on the surface of the stools. Has not been feverish lately ; no griping or straining ; no pain in abdomen ; no imeasiness in anus ; pulse gaining strength. Medicine and diet the same. 24th. — He is feeling comfortable, and is steadily improving. 104 TROPICAL DYSENTERY AND DIARRIKEA. MedicineB continued. Diet same ; extra rice (boiled) eiglit ounces. 25th. — Owing to sudden change in the weather, he felt feverish last evening. Temperature dd-Q"^. Number of motions diminishing. In all other respects seems to be improving. The same medicines and diet. 26th. — Improving. Motions getting thicker ; no traces of pus noticed. Same medicines. Milk and bread diet ; mutton curry and buttermilk eight ounces. Omitted gallic acid; aromatic chalk with opium gr. xx. every six hours. 28th. — Patient is doing well, but looks pale and angemic. Number of stools considerably reduced, and their consistence increasing. Some pus has appeared in the motions. He was ordered to have an injection, composed of half a drachm of aliun dissolved in four ounces of cold water, twice a day. He was further ordered to have thirty drops ferri pemitrat. twice a day. Diet the same as before. 30th. — Improving. October 1st. — Henceforward to October 12th he continued to make a steady progress towards recovery. He gradually gained strength, lost his pale and bloodless aspect, had a very good appetite. The number of motions became less, and fii-mer in consistence ; the purulent discharge disappeared. He was discharged cured on October 15th. Case 17. — Asthenic Dysentery, with Hemorrhoids and Enlargement of Spleen. Campbell Hospital. A. A., aged forty, a shij) Lascar, native of Eastern Bengal, admitted on September 1st, 1880. Yery weak and emaciated. Has suffered from prolonged malarious fever ; has enlarged spleen ; and for the last two weeks has passed seven or eight stools daily, which, he says, consisted of mucus, blood, and some fseculent matter. They were attended with tenesmus and griping, whilst there was a constant griping pain about LECTURE II. 105 the umbilicus. He also suffers from internal hsemorrlioids, which occasionally bleed freely. Has no fever at present ; pulse small and soft ; skin dry and harsh ; tongue moist and clean ; no appetite. Three days after admission the calls to stool increased to fourteen or six- teen daily, the evacuations consisting of reddish and yellow liquid foeculence with blood-clots, but no mucus ; pain on pressure over sigmoid flexure ; tenesmus had increased ; the left eye is painful, with profuse lachrymation and photo- phobia. September 5th. — Is feverish. Less frequency of action of bowels ; stools eight to ten in twenty-four hours, of the same character as yesterday. Pain on pressure over splenic flexure of colon. 6th. — Is weaker. Twelve stools during last twenty-four hours, of an ochrey-reddish colour ; on washing these, fsecu- lent branny sloughs were detected. Tenesmus and tormina considerable. Fever came on last night. Left eye is painful, and the lower segment of the cornea is opaque. The other eye is cataractous. Straining is severe, and has produced prolapse of the bowel. Temperature normal. Tongue clean and moist. Does not sleep and has no appetite. Up to the present report he has been taking five-grain doses of euphorbiaeeous extract three or four times a day, biit with no apparent benefit. Now he is to have gallic acid gr. v., cinchona alkaloid gr. iij., dil. gal. acid tTl.x.,liq. opiised. v^x., rum 5ij., decoct, koorchee 5vj., every six hours. Belladonna and cotton-pad for the eye. The next day he was easier and slept better. Motions less frequent. No fever. Eye less painful. 8th. — Number of stools again increased. Motions highly offensive, and contain clots of blood. Straining and griping less. Micturition difiicult. Continue all as before. 10th. — Free from fever. Motions more frequent in the last forty-eight hours. Is weaker ; unable to rise fi'om his bed. Dejections of a reddish colour. There is pain in the left iliac region. Tongue dry. Looks dull and heavy. Pulse very feeble. No appetite. 106 TROPICAL DYSENTERY AND DIARKHGvV. 11th. — Eight or ten motions in the past twenty-f oiu' hom-s, of a reddish colour. Blood-clots and shreds of slough also present. In the afternoon, after the bowels had acted, he became collapsed, and sank early next morning. Post-mortem. — Body emaciated. (Edema of feet. Head not examined. Chest : Limgs slightly adherent to thoracic walls by old adhesions ; crepitant and healthy. Heai"t : No pericardial effusion ; natural in size ; muscular substance pale and flabby. Eight ventricle contained a large decolorized flbrinous clot, extending into the pulmonary artery ; left ventricle contained a small loose clot of blood. Valves and pericardium apparently healthy. Abdomen : Liver of normal size ; textm^e firm, but of a pale colour. Grall-bladder full. Spleen much enlarged; its capsiile thickened; trabecidar structm-e firm and dense ; pulp very soft and dark. Kid- neys apparently healthy. Intestines : Ileum in a state of hypersemia, but not ulcerated. The whole of the large intestine highly congested. Numerous idcers, some cii'cular, some irregular with jagged edges, affecting only the mucous membrane, occupied the mucous membrane throughout, but most in the. sigmoid flexure and rectmn. The muscular coat appeared to be imaffected. The peritoneum was healthy. The hoemorrhoidal vessels, varicose and dilated, contained dark blood-clots. Case 18. — Dysentery with Renal Disease. Campbell Hospital. M. C. D. B., aged thirty-five to forty, admitted on August 8th, 1880, and discharged on September 17th, 1880. He is a village chowkedar (watchman). Had been exposed to night air and vicissitudes of weather. Had not been in the habit of diTuking. Never had rheumatism or any eruptive disease. Some years ago had an attack of dengue, and had hurt his loins by a fall, since which time he has been subject to severe lumbar pain. LfX'TURE IT. 107 Thi'ee months ago he had a severe attack of remittent fever, and when recovering, dysenteric symptoms set in. For this he had been li\ang on dhai (curds — a native article of diet), but had taken no medicine. He was improving, when suddenly he became anasarcous and ascitic, in which state he was admitted. There was great dyspnoea. Face puffy ; whole body, hmbs, and scrotum oedematous. Urine scanty, very albuminous, and contained granular and hyaline casts, and there were frequent evacuations of blood and mucus, with tormina and tenesmus. There were daily returns of fever, which intermitted towards evening. Ipeca- cuanha and bismuth were given, but vdth no reUef ; gallic acid, with opium and koorchee, were then prescribed, and under this treatment the symptoms rapidly abated. The evacuations became healthier and less in number ; the griping and tenesmus diminished ; the abdominal pain and the fever disappeared. The anasarca was also greatly relieved by punctures, as much as sixteen pints of clear serous fluid flowing from them in twenty -four hours. The drain continued for some days, and gave great relief. Iron was then given. The improve- ment continued so much that on September 17th he was discharged. The history of this case is not knowTi after he left. It is to be feared that the relief may only have been temporary ; but it is interesting as sho^\'ing the eompHcation of renal disease, and the amount of rehef that was afforded. Case 19. — Dysentery avith Fever — Enlarged Spleen. Campbell Hospital. J., aged nineteen, Hindoo labourer, from the North-West ProAonces ; of intemperate habits. Admitted July 9th, 1880, died August 17th, 1880. Thi-ee months previous to admission suffered from malarious fever and enlarged spleen. As he was getting worse he was 108 TROPICAL DYSENTERY AND DIARRHCEA. sent to hospital. Besides the usual symptoms of intermittent, and greatly enlarged spleen, there was extensive pleuritic effusion into the pleural cavity on either, but most on right, side. There were also dysenteric symptoms of severity. For a day or two after admission he had six to eight scanty muco-sanguineous motions ; they soon increased to fifteen to twenty daily. They were mingled with more or less semi- liquid fajculence. At first he did not complain much of tormina or tenesmus ; latterly they became urgent, and he was distressed by severe pain, as if some foreign body were in the rectimi, especially in the evening. There was daily recurrence of fever, dyspnoea, and cough, which, after a time, was attended with muco-purulent expectoration ; inability to lie down, excessive debihty, feeble rapid pulse, indicated his precarious state. There was now little or no pain in the abdomen or hepatic region. On washing the dejections they were found to contain small pieces of pus-infiltrated greyish sloughs, some being of a black colour. For a few days he took ipecacuanha, bismuth, and Dover's powder; but they did no good, and were substituted by gallic acid, opium, and koorchee. Oj)iate enemata were also administered, but he could not tolerate the syringe. Suppositories were given instead, with good effect. He got weaker, however, and was supported as much as possible by nutriment and stimulants. The dysenteric symptoms and the fever abated ; but collapse and apnoea set in, and he died. No surgical attempt had been made, on account of the debihty, to remove the fluid from the chest. In addition to the usual post-mortem appearances found in cases of pleuritic effusion, and a very much enlarged spleen, there was nothing very unusual in the appear- ance of the serous surface of the intestines. The ileum did not appear to be much congested. The cahbre of the large intestine seemed to be narrowed. On laying open the gut the mucous membrane of the large intestine was found to be of a slate colour, and ulcers of various sizes existed there, especially in the sigmoid flexure. Two large oval ulcerated patches were met with just at its lower ter- leci'l:re II. 109 mination, and it was apparent that all down to the serous coat was destroyed. There were puckered cicatrices of old ulcerations, contracting the bowel, seen here and there. Spleen greatly enlarged. Liver also enlarged, and appeared to have undergone fatty infiltration. Note. — The state of the heart is not noted, but no doubt the right side and the pulmonary artery were plugged Tvith white fibrinous clots, and that they caused the breathlessness and collapse which preceded — indeed actually caused — death. Case 20. — Sloughing Dysentery and Cirrhosis of Liver. Campbell Hospital. B. Gr., aged twenty-six, a Hindoo labourer, admitted on September 13th, 1880. Has been in the habit of drinking rmn for the last four or five years. When he was in his native country, the North- West, he was in the habit of drinking spirits distilled from mahooa (Bassia latifoli'i). For the last three months he has been out of health, with general weakness, and for six weeks from dysenteric s_}Tnp- toms and quotidian fever. At first he had loose fceculent stools, but lately the motions have increased in number, and are mixed with mucus and blood, attended by tenesmus and severe pain in the lumbar and right iliac regions ; the latter is tender on pressure. His skin is cool ; tongue clean and moist. Has long lost appetite, and suffers from acidity, nausea, and vomiting. Pulse very slow and weak — in the right wrist forty-one beats, and in the left thirty beats per minute were counted. Passes m-ine freely. Heart's action excessively weak and slow. Area of hepatic dulness, both upwards and downwards, considerably diminished — so much so that the space occupied by the seventh and eighth ribs appears to be the only dull spot in the right hypochondrium. There is atrophy of liver, and no per- ceptible enlargement of spleen. Was ordered — p. ipecac, gr. 110 TROPICAL J)YSENTRRY AND DIARRHOEA. iv., p. ipecac, co. gr. vj., bismuth gr. v., giun. acaeia3 gr. v. — misce ; one powder, once every eight hoiu-s. Turpentine stupes. Milk and rice diet. September 16th. — Had about forty-eight motions dui-ing the last twenty-f oiu' hoiu's, perfectly liquid, and in colour and consistence like " meat washings." In the liquid are seen floating some yellow-coloui"ed faeces, covered with a coating of mucus. On washing, numerous small scaly and branny sloughs of a grey colour and some clots of dark blood with mucus, like boiled grains of sago, were seen. Had no fever ; is very weak ; pulse 44. Tenesmus, with pain, fulness, and hardness in the right iliac fossa. Has vomited four times, and brought up two living lumbrici. Has passed small quantities of urine with the motions. Medicine continued. Spoon diet ; milk two pints. 17th. — Dui'ing the last twenty-foiu' hours has had numerous stools — niunber not counted. Motions not quite so liquid as before ; of a dark coloui" and very offensive. A few small masses of yellow-tinted casein are seen floating. On being washed, numerous thin branny sloughs, mth clots of blood and some liimps of gelatinous mucus, were seen in the dejections. He says that there is violent straining and griping. Pain and much tumefaction with some indiu^ation in the right iliac region. No fever mthin the last twenty- foiu" hours. Had no sleep and was very restless. No appetite. Tongue moist and clean. Pulse exceedingly small, weak, and slow. Morphia sleeping draught at bed- time. Spoon diet ; milk two pints. 18th.— Had no fever. Frequency of calls to stool less ; had only twelve during the last twenty-foiu' hom-s. Motions consist of copious yellowish- coloiu'ed liquid, covered with green-tinted frothy matter. On washing the excreta, a few blood-clots but no sloughs foimd. Micturition easy. Slept better. He looks anxious and much pinched and shiamk. The swelling in the right iliac fossa is very tender ; he cannot bear the least pressure ; on percussion there is dull resonance. He keeps his legs drawTi wp towards the abdomen in the recumbent position. Pidse weak, small, and slow. Tongue LECTl KK II. Ill clean, but dry. Has a fail- appetite. Vomited once. Con- tinued powders, enemata, and sleeping draught. Large warm bran poultices on abdomen, to be changed frequently. Spoon diet and two pints of milk ; rmn two ounces. 19th. — He had fever last evening, but it has passed off. Skin now cool and soft ; pulse weak and slow. Did not sleep till towards the morning. Nimiber and frequency of stools have again increased ; had about thirty-five motions in the last twenty-four hours ; some portions of yellow fseculent matter seen. Local pain and swelling continue as before. Omit ipecac. I^. Grallic acid gr. vij., dil. sidph. acid v\_x., opii sed. Vfix., rum oij., decoct, koorchee 3vj. ; for one dose every three hours. Warm poidtices. Diet, milk and sago ; rum two ounces. 20th. — Slight fever again last evening ; no sleep last night. Had thii*ty to thirty-five motions during the last twenty-four hoiu's ; some greenish-yellow, frothy fseculent matter is seen floating on a liquid of a light-di'ab colour, which, on being washed carefully, was foimd to contain small globular masses of gelatin oid mucus and a few jagged shreds of grey-coloured slough. No griping or straining ; local pain and swelling continue, but the hardness is less ; on percussion, the resonance is dull. He is getting weaker. Tongue red, diyish, but clean. Urine scanty, but voided mthout difiiculty. Had no vomiting ; no appetite. Continue medicines. Diet the same. 21st. — Had slight fever last evening. Bowels moved about twenty-thi-ee times during the last twenty-foui* hom"s, containing semi-liquid yellow-coloured and pm'ulent matter, but without any blood. On washing, a dead round wonn, some fragments of dark slough, and small masses of mucus were seen. Had some sleep, and took a little more nouiish- ment than before, Pulse 88, but very small in volimie ; tongue red and drjash. Pain in the right iliac fossa and swelling diminished. Percussion elicits a clearer resonance. No griping or straining. Medicines and poultices continued. Diet same. 22nd. — Had about seventeen or eighteen stools in the last 112 TROPICAL DYSENTERY AND DIARRHOEA. twentj-foiir hours ; motions again liquid, of a faintly yellow colom', and very foetid. On being washed, tliey were found to contain a few black shi-eddy sloughs. No griping or straining, but is constantly moaning fi^om pain in the right iliac region. Swelling and hardness much reduced in size, but on further pressure and light percussion an indistinct gurgling sensation is felt. Yesterday, at 4 p.m., patient was reported to have been slightly feverish ; but at 5.30 p.m. the temperatm-e was 98-8°. He is very low ; speaking voice almost inaudible. Continued medicine. Diet the same. 23rd. — Had slight fever last evening. Bowels moved fifteen times since last report. Motions scanty, and consist of very putrid, chocolate-coloured, thick liquid, in which are seen suspended three or four small lumps of freculent matter of a yellowish colour, enveloped in a coating of grejdsh mucus. The chocolate portion, on being mixed with water, became of a reddish colour, and at the bottom of the vessel some pieces of branny slough, as also a few small clots of blood, were seen ; no gripings or strainings, but there is a general diffused pain in the right iliac hypogastric region, which increases on pressure. Countenance cadaveric ; eyes and cheeks simk ; voice husky ; tongue quite dry and red ; pulse barely per- ceptible ; skin dry, but colder than natural ; has no hiccough, but has vomited ; sleep disturbed. Takes almost no nourish- ment, and is very low. Continue medicine, soup, and rum. To relieve pain, some extract of belladonna and glycerine applied over the abdomen. 24th. — Is very low. Temperature last night was 97'6°. This morning the extremities are very cold ; the weather has been chilly and wet, but he cannot bear to be covered. Pulse barely perceptible at wrist. Had twelve stools dming the last twenty-four hours, which consisted of dark venous blood. On washing, the dejecta became hght red in colour; at the bottom of the pan much dark blood-clot and shi'eds of black slough were seen. Tongue brown and dry ; vomited twice ; hiccough troublesome. Has passed a small quantity of urine with the stools. Pain and the peculiar doughy feeling in the LECTURE II. 113 abdomen continue as before. Some diffusible stimulants were given during the day, and the night following. He became low, and died at 4 a.m. next morning. Post-mortem, four houi's after death. — Body emaciated. No cedematous swelKng of the limbs. No rigor moi-tis. Head not examined. Chest : Lungs apparently healthy and crepitant ; no adhesion, no signs of hypostasis. Heart pale and flabby, other"\vise apparently healthy. Abdomen : In the cavity of the abdomen signs of recent peritoneal inflammation were present. Here and there, soft and recently effused yellowish lymph was found covering the coils of the intestines. The lower portion of ileum and all the large intestines were of a dusky reddish colour outwardly. The sigmoid flexure of colon was drawn towards the lower part of the right iHac fossa, and was adherent, though not very fii-mly, to the lower portion of crecuni. Both the portions of the intestines were of a greyish-black colom-, and on attempting to detach them from the right iliac fossa, the point of adhe- sion gave way, and their foetid contents were extravasated. On removing the large intestines with a portion of the ileum, and laying open and washing them, it was found that no ulcerations existed in the ileum. The ileo-ccecal valve appeared to form a barrier to the progress of the ulcerative process upwards. But the whole of the caecum, the lower portion of the ascending colon, its hepatic flexure, the lower portion of the descending colon, the whole of the sigmoid flexiu'e, and the entire rectum, were a mass of ulceration and gangrene. The mucous membrane was entirely destroyed thi'oughout, and the muscular coat presented a dark grey-coloured sodden sm-face. The lower portion of the sigmoid flexiu'e at one side was a mass of jagged slough, black, charred, and very putrid, of about five or six inches long. The whole of the mucous membrane had sloughed away, and its subjacent muscular coat was seen projecting on an irregular and fungoid granu- lating sui'face between the excavations. In the transverse- and descending portions of colon, the mucous membrane did not seem to participate so much in the morbid changes, but was of a grey and slaty coloiu'. The portion of the 114 TROnCAL DYSENTERY AND DIATIRHGEA. sigmoid flexure which was adherent to the ccccuiu was completely gangrenous throughout. Liver completely cirrhosed, much rediiced in dimensions and weight. Its outer siu'face irregular and studded throughout with small hard prominences. Left lobe reduced to a very small size, and the right lobe of a globular form. The edge of the organ has become quite thin and membranous. The portal canals siuTOunded by thick, dense, and white bands of fibroid tissue. The structure of the gland coarse and pale. Capsule much thickened and dense, but on carefid examina- tion was separable from the gland stiiicture. Some super- ficial veins ramifjong on the sm'face of the liver were considerably dilated. Gall-bladder contained a very small cjuantity of thin and pale-coloured bile ; its duct, and those of the liver, appeared pervious. Spleen considerably en- larged ; its capsule thick and of a dense whitish colour ; pulp very soft. Kidneys not examined. Morbid Specimexs (Dr. McCoxxell, CALcrxTAK No. 1. — Acute Bi/soifcrj/. A Mahomedan, aged thirty, admitted into the Medical College Hospital, Calcutta, with acute dysentery of about ten days' duration. The whole of the large intestine is affected. The mucous membrane presented a bright rosy-pink colour in the fresh state. The sub-mucous tissue is thickened, and the whole sui-f ace of the bowel is covered ^ith innimierable small super- ficial ulcers, roimded or oval in shape, none larger than a two- anna piece, and almost all of them exhibiting a roughened and granular appearance, fi"om recent yellowish fibrinous effusion over their sm-faces and margins. The ulcers are extremely numerous in the descending colon, sigmoid flexure, and rectum, and this portion of the bowel is contracted in cahbre. The thickened and vascidar condition of the bowel extended from the ca}cum into the ileum continuously for almost six inches. LECTURE II. 115 The large intestine contained about an ounce of thin yellowish fluid, consisting almost entirely of shreddy mucus. There are no notes of the progress or dui'ation of this case, but it is not probable that death was caused by the mere lesion of the bowels. The patient must have succimibed to the general effects of the disease on his constitution. No. 2 — Acute Dysentery. A Hindoo, male, aged thirty ; died on February 7th, 1880, on the eleventh day of an attack of acute dysentery. Medical College Hospital, Calcutta. Portion of the large intestine. The mucous membrane presents a bright rosy-pink colour, more intense in parts, and is covered with numerous super- ficial serpiginous idcers. These were most abundant in the ccecum and ascending colon, and again in the sigmoid flexure and rectmu. The sub-mucous tissues are a good deal thickened. The patient was in a very broken-down state of health from secondary syphilis, and had recently under- gone merciu-ial salivation. The stools were ten or twelve in the twenty-four hours, and contained an abundance of gelatinous mucus. Here again the cause of death could not liave been the bowel lesion. No. 3. — Acute Slouglting or Catarr/w-Fibrinous Dysentery. Medical College Hospital, A Mahomedan, aged forty. Admitted December lltli, 1879 ; died on December 15th. The disease was of fifteen days' dm-ation on admission. He was greatly prostrated ; severe griping pain all over abdomen, increased on defseca- tion. The stools, twelve to fourteen in twenty-four hours, consisting largely of blood, flaky mucus, and highly offensive putrilage ; no fseculence. Large intestine examined. The I 2 116 TROrifAL DYSENTERY AND DIARRHCEA. gut is diseased, from the crecum to the anus it is swollen and rigid; all the coats greatly thickened. The mucous surface is covered with large, mostly transversely placed, sloughs or raw-looking ulcers. The latter have (in fresh state) vividly injected pui-plish and dark-pink margins ; their bases are formed by the swollen, sodden-looking muscular coat. In the sigmoid flexure the ulcers are deep ; their surfaces present secondary dark gangrenous-looking slough- ing, while their margins are overlapped by recent granular rosy lymph. No. 4. — Acute Fibrinous BijHentery. Medical College Hosj)ital. A Hindoo male, aged thirty. Admitted July 13th, 1880 ; died July 16th, 1880. Dysentery of eight days' duration, according to his own statement. During life the stools ^^'ere very numerous, contained much blood and blood-tinged flaky mucus, and latterly small bits of dark slough. .The whole of the large intestine and adjacent six inches of the ileiun preserved is covered by a granular exudation of lymph — ^the extension upwards of the disease in the large intestine. The mucous membrane of the latter, from cseciun to anus, is covered with tranversely placed sloughing ulcers ; in addition to which there is, over the lower two-thirds of the gut, a copious exudation of yellowish-white recent lymph, which invests the margins of the idcers, and even the siu'faces of the sloughs which have separated. These ulcers are deep red and raw-looking. They reach to either the sub-mucous or mus- cular coat. In the rectum there are several loosely adherent sloughs, which present a very dark gangrenous appearance. The whole of the large intestine exhibits great rigidity and thickening of its walls. This is a typical case of the worst form of dysentery, short of that in which the whole gut passes into a state of sphacelus. LKCTURE U. 117 No. 5. A tubular slough, about nine inches in length, from the ascending colon of a native male patient, aged twenty-four, who died in the Medical College Hospital on January 21st, 1875, fi-oni dj'sentery combined with multiple abscess of the liver. This is an excellent illustration of the large size to which these sloughs may attain. It is not stated what its composition is — whether mucous membrane alone, or com- bined wdth sub-mucous, and perhaps some muscidar, tissue ; or if it be simply diphtheritic, and thrown off from the surface. I am indebted to Professor Aitken, of Netley, for the following specimens fi'om the Netley Museiun. They illus- trate some of the points to which I have alluded : — 1. Commencing contraction of rectum after dysentery. 2. Pin-hole perforation after dysentery. 3. Contraction of Colon. — Captain M., P.N., suffered from dysentery in China in 1857 ; died December 12th, 1876, after seven days' illness. "Was a man of great activity up to date of last illness. Suffered from intestinal initation and constipation. Death from heart and aortic disease ; adhesion of colon immediately in front of spleen. Strictiu'e admits a ball = 0"29'' diameter ; colon distended above stricture ; ulcer in caput caec. 4. Numerous large abscess-cavities in liver ; liver of large size, protruding high into thoracic cavity, and compressing limgs, and thrusting heart out of place towards left; after the discharge of pus, weight 14 lbs. 5. Exuvise passed by stool. 6. Exudation dysenteric ; gut commencing to thicken. 7. Dysenteric exudation. In my next lecture I shall describe the treatment of the sub-acute and chronic form of dysentery. LECTURE III. Mk. President and Gtentlemen, I PURPOSE to-day to consider the subject of chrouic dysentery, the morbid changes in the abdominal viscera that accompany it, and the treatment, especially of those cases that are not unfrequently seen in this country as the result of disease contracted in India, China, or the tropics. Having disposed of this, I shall pass on to consider tropical diaiThoea, but chiefly that form of it which so frequently follows, and in many instances probably really is a form of, chronic dysentery ; and to this I would particularly invite your attention, as it is so often met with among returned Indians and others, and is a form of disease which, though always serious, is, under favoui'able circumstances, more manageable and amenable to treatment than might be supposed. From the nature of the complaint, it is more frequently met with here than abroad, excepting in cpiite the earlier stages, for the reason that Europeans are generally recommended to quit the country where it began to affect them. Much might be said, did time permit, in respect of the low forms of diarrhoea that occur" in the ill-fed, mala- riously poisoned, anaemic natives, so often seen in some parts of India, in gaols and other localities, but especially of late years among the sufferers from starvation during famines. The diseased conditions resulting therefrom have been the subject of special investigation recently by Dr. D. D. Cunningham, who made a most careful and exhaustive examination of the pathological changes that took place in LECTURE III. 119 the intestines of the famine-stricken inhabitants of Southern India. I shall refer to his report, which not only throws much light on the special pathology of famine bowel-com- plaint, but has an important bearing on chronic diarrhoea generally. In my last lecture I discussed the subject of acute dysentery and its treatment, the chief element of which is the use of ipecacuanha in large doses. I said little about any other remedy — except opium, which, even in the acute stages, is often urgently needed — for really none other are, as a rule, necessary. But, in the conditions of which I have now to speak, other remedies may be required, according to the state or stage of disease, and it is to these I now ask your attention. First let me speak of the sub-acute condition, in which dysentery fi"equently occurs, and into which the acute form is liable to pass by recurrence of dj^senteric action in the bowel, from any cause, after the first acute s^nnptoms have passed away, or, as may happen, when it assumes this state from the outset, or, as it may be, after complete subsidence of the acute cataiThal condition, when there is supervention of ulceration in the glandular structures and in the mucous membrane of the bowel. By sub-acute I mean that variety where the sjTnptoms indicate that some activity in the dysen- teric process is present. There is pain, tormina, and tenes- mus, though less than in the acute, and, when the disease has lasted some time, it is probable that ulceration, though not necessarily extensive, has taken place. In such cases ipecacuanha must again be resorted to, and probably the combination of bismuth, carbonate of soda, and quinine. The latter, if there be any malarial taint, is especially desirable. When there is much pain on pressure on the abdomen, and the thickened gut can be felt on palpation, counter- irritation, over the part most affected, is likely to be of service. When there is much tenesmus, indicating rectal complication more than usually severe, opiate injections and large enemata of warm water ai'e indicated ; Dover's powder at night, and 120 TROPICAL DYSENTERY AND DIAKRHtEA. injections of two grains solution of argent, nit. to the ounce of water. As the sub-acute symptoms abate, and give place to those of a more ckronic character, indicated by still frequent evacuations, with more or less straining and tenesmus, the discharges being mucous and occasionally tinged vrith. blood, the internal use of twenty-drop doses of oil of turpentine, guarded by small doses (say ten minims) of tr. opii, every third or foiirth horn-, will be of service. Indeed, tliis is a remedy to which I attach much impoi'tance. I first became acquainted with its efficacy in Bennuda, in 1843, when I saw it administered vdth good results in the treatment of dysen- tery in the Roj-al Naval Hospital there, by Dr. G. King. Its value was so highly estimated that it had a reputation scarcely inferior to that now enjoyed by ipecacuanha. I beheve it was subsequently found to be of ser%'ice in the dysentery of China in the hospital-ship at Hong Kong, but of late years I have heard little or nothing of it ; it has been superseded by ipecacuanha. In the stage of ulceration, I repeat, I have foimd it exceedingly usefid. Its power of stimulating vascular action and of expediting the reparative processes is shown by its power of causing granulation in an indolent chronic ulcer, say on the leg. "\^'^len given in fifteen to twenty-minim doses the effect is most remarkable ; the surface becomes florid instead of dusky, red granulations form, and cicatrization rapidly residts. I have no doubt it acts in a similar way in the ulceration of the bowel, and I have often been gratified -SNith the rapid improvement that has attended its use. "V\Tiilst any sign of activity in the dysenteric process continues, it is imperatively necessary that the strictest attention should be paid to diet, and that all solid or in'itat- ing articles of food should be carefully avoided. The use of alcoholic stimulants must be most carefully regulated, and, as a general rule, when there is no special reason arising out of former habits or great depression of the ner\ous system, it is better to avoid them entirely. The greatest attention must be paid to clothing ; flannel LECTURE 111. 121 should be worn uext the person ; chills and sudden alterations of teniperatm-e most carefully avoided. All irregularities of living must be sedulously shunned. Chronic dysentery is of more than one kind. There is that which follows, or rather is left by, an acute attack, when it has not yielded entirely to treatment, and the bowel has become structurally diseased — i.e., ulcerated, thickened, congested — after the first urgent symptoms have passed away. There is another variety, whicli never was acute from the beginning, or scarcely even sub-acute. It begins insidiously, and goes on so. It is truly chronic, may last for years, and then the two forms are somewhat alike, though in their origin they essentially differ. The chronic form that follows the acute is apt, indeed, to be more severe and to prove more frequently fatal than the other, which is more enduiing, occasionally intermits, and though in the end perhaps fatal, is more slowly so. I have only recently seen a lady who suffers from this form of chronic dysentery, who first came under my care in India fourteen or sixteen years ago. Even then it was not the fu'st attack. Though frequently ill and debilitated, this lady could not be said at any time to suffer from more than chronic dysentery, and, to say the least of it, her health is as good now as it was ten or twelve years ago. I know others who have suffered for years, and even go backwards and forwards to India. But what a precarious life ! Such cases, no doubt, are familiar to many of you, for it seems to me that they are not very uncommon, and that a considerable share of the trouble to which old tropical or Indian residents are liable is due to this disease. They are very apt to be troubled with haemorrhoids, either internal or external ; and it may be difficult to say how much of the symptoms is due to the hoemoiThoidal affection, or how much to chronic vdceration of the bowel higher up, or how far they may be attributed to contraction and stricture of the gut ; such stenosis of the rectum being Hable to induce attacks of tenesmus and the passage of mucous stools tinged with blood. The admixture of the mucous or sanguineous discharge icith 122 TROPICAL DYSENTERY AND UlARRIKEA. fseculence points to rectal dysentery ; whilst the blood and mucus following the discharge of fsecal matter indicates the hsemon'hoidal condition. In many cases it is exceedingly difficult to differentiate one from the other, nor indeed is that possible where the two conditions co-exist. Such cases are liable to frequent intermittent attacks of acute or sub-acute mischief, and cause great suffering ; others, though not liable to recm* \dih. such violence, are brought on after the least exposure to chill, the disordered digestion and functional derangement of the liver and portal congestion accompanying that state render the subjects of them more or less chi'onic invahds. So long as the thickened and ulcerated state of the bowel continues, so long is the person liable to suffer from sjTnptoms of chronic dysentery. In the treatment of chronic dysentery a most essential element is removal from the place where the disease was contracted, if the patient can bear it. Not to the hills, where rarefied au' and low temperature would be injurious ; but change of climate is necessary. If in Bengal, for ex- ample, a sea-voyage to begin mth, or, better still, a visit to Europe, where the patient should remain until the symptoms have been removed, and for some time after the action of the bowels has been restored to the nonnal state. The pathological conditions of the bowel are interesting and various. There is either a continuous state of chronic ulceration in some part of the gut, which is tliickened and indurated, or there is stricture from the cicatrix that has been formed, and it may be that the whole calibre of the intestine has been contracted until complete stenosis forms. In this state it is necessary that the patient be carefully watclied, and symptoms treated as they arise, the closest attention being paid to his diet and in protecting him from \dcissitudes of climate. Dover's powder, with bismuth and sod. carb., in five- or ten-grain doses, combined, especially if there be pain or tenesmus, shoidd be given, with immediate recurrence to the larger doses of ipecacuanha if any symptoms of acute or sub-acute mischief recur. Sulphate of copper in quarter- grain doses, combined ^vitll half a grain of opiimi, in a pill ; LECTURE HI. 123 or the turpentine (as before mentioned) in fifteen- and twenty-drop doses three times a day may be given. Solutions of iron (especially if there be ansemia), quinine, and nux vomica have their advocates ; and there are several remedies well known to the natives of India that have good effects. The bael {JEgle marmdo^), the koorchee [Wrighfii anti-dysenteriea) in decoction, are often efficacious, and there are astringents that enjoy more or less repute. Let me give a brief description of the cases in which the bael fruit is likely to be useful. In the chronic condition of dysentery — in which the bowel is thickened, ulcerated, or indurated from cicatrization, and subject to reciuTence of sub-acute action, indicated by straining and the discharge of mucus and blood, and the entire intestinal mucous membrane is sympathetically in- volved — the use of the fresh bael is likely to be of service ; but it may be necessary to associate it with other remedies, such as opium or Dover's powder. From the power it possesses of giving tone to the alimentary canal generally, of improving the condition of the mucous membrane and its glandular apparatus, and of favouring cicatrization, it will not unfrequently aid in producing satisfactory results where other remedies, even tm-pentine, have failed. Vegetable and metallic astringents and tonics — such as kino, catechu, tannin, hsematoxylin, eucalyptus, Wrightii anti-dysenterica, pome- granate, sulphate of copper, acetate of lead, alone or combined with opium, — may give temporary relief, but the disease continiies to advance, the least error in diet, or alteration in temperature or hygrometric condition of the aii', aggravating the symptoms. Such cases are not infrequent in this country ; and no doubt the patients have taken the wisest and most effective step for restoration to health in coming home — one in comparison with which drugs are insignificant. In such cases the bael will sometimes materially aid in restoring the diseased intestine to its normal condition. Of course it will not alleviate all the morbid conditions that may arise in cases of chi'onic dysentery, and recurrence of acute sj'-mptoms may need more active treatment. But I think r24 rHOPlC'AL UYSENTEllY AND DIAUIUKKA. you will sometimes find under its infiuen(.;e that the re})ara- tive changes in the large intestine progress quietly, until cicatrization is accomplished, thickening is removed, and, as far as may be, healthy action is restored. Unhappily, many cases have not so favourable a termina- tion, and the result is fatal, after long and severe suffering : the structural changes in the bowel are beyond repair, and the patient at last succumbs. In others the disease, though not fatal, is very tedious : a cicatrix may form, but the gut remains thickened, indurated, and contracted, its fmictions are imperfectly performed, and a condition of chi'onic disease and suffering remains ; diarrhoea, sometimes dysentery, continues, and the patient is worn and wasted by continued suffering. The evacuations are light-coloiu-ed — grey, sometimes yellowish — often passed without pain or tenesmus, but at times accom- panied by both, and mingled with blood and mucus. This ultimately luidermines the strength, and the patient sinks from exhaustion. In the stages that lead to this state of things the bael is likely to be of service in retarding, if not in altogether checking, the mischief. It is desirable that the bowels should be kept free from accumulations. This may be effected by small doses of castor oil or by saline laxatives; and one cannot too strongly insist on the necessity of obAaating congestion of the hepatic and portal circulation. Enemata of tepid water or of congee- water (rice) to wash out and soothe the bowel, the use of opiate enemata at night to allay tenesmus and give rest, are useful ; and in the rectal form of dysentery, as Dr. McLeod says, local medication with injection gr. ij. to §j. solution of nitrate of silver, of ergot gr. xij. in some starch, or five or six grains by the mouth, may prove very useful. The warm bath is sometimes beneficial, and all measm'es that insm'e rest or have a soothing action. Where the bowel is thickened and tender on pressure, the application of a blister over the tender part, or of tincture of iodine — the counter-irritation being maintained for some time — may be useful ; and, above all, the diet must be carefully regulated, consisting of mild, unstimidating food, solids only LECTURE 111. 125 being given with the greatest care. Kest and time, "svith the above measures carried out in a favoui-able climate, are hkely to be successful. But whatever is done, time is essential. Where complications exist, they must be dealt with according to theii' nature. Haemorrhoids must be prevented from causing haemorrhage, and if they are painful or swollen must receive such local treatment as their condition suggests. Splenic en- largement with cachexia will requii'e quinine and iron, or iron alone ; hepatic enlargement demands such measm^es as are in- dicated by the nature of the enlargement. Should liver-abscess gradually supervene, it must be watched, the strength sup- ported, and, if it seems practicable, the pus must be evacuated ; and you will find, as shown in a case I shall relate, that liver- abscess is not always multiple when it occurs in combination with, or, as some think, in consequence of, dysentery. In chronic dysentery of the scorbutic type, indicated by the spongy, bleeding state of the gimas, and the general state of cachexia, perhaps associated -with splenic mischief, prepara- tions of iron, the solution of the pernitrate, iron and quinine citrate, potassic tartrate, or other easily assimilable form, with vegetables, lime-juice, and carefully-regulated diet, are needed ; and in those cases where malarial poisoning has induced anaemia, splenic cachexia, and general atrophy of the tissues, including the mucous membrane and glandular structure of the intestine — a condition which is manifested by diarrhoea, a low adynamic tj'pe of disease, which is as much dysentery as diaiThoca, and forms, no doubt, a large proportion of the cases called tropical diarrhoea (of which more anon) — it may be that milk is the only food that will be assimilated, and the use of it the only treatment on which any reliance can be placed. Some of these cases of chronic dysentery recover under the influence of change of climate, careful dieting, absolute rest, attention to symptoms as they arise. Medicines, no doubt, are at times of great service, but recovery depends more on hygienic measures and proper food than on di'ugs. Many patients linger for months or years, and succmnb at last. The lesions in the bowel are never repau-ed. Not only 126 TROPICAL DYSENTERY AND DIARRHCKA. is the large intestine thickened or atrophied, ulcerated or contracted, but the small intestine also becomes atrophied and degenerate. The mucous membrane and its glands are wasted, the power of absorption is gradually lost, and the patient sinks from inanition and asthenia. The value of ipecacuanha in the treatment of this form of dysentery, when, years after the first attack, there is at any time a return of the acute symptoms, is great. By timely attention to this, much suffering may sometimes be spared, and a patient relieved, who otherv^dse might have drifted into a hopeless condition of chronic dysentery. The question is often asked, in the case of persons suffer- ing fi'om chronic dysentery, where they had best live in this country ? And I generally reply that they may live almost anywhere if there be a home, with its special comforts, good niu-sing, and dietetics ; but when these are attainable any- where, then to select some diy and not too much exposed locality, avoiding the vicinity of low or swampy ground, — to be on gravel rather than on clay. Avoid the east coast in the ^\inter ; select the milder air of the South of England — Hastings, Boui-nemouth, Torquay, etc. If the cold of the winter or spring be much felt, as it often is, go to the South of France or the Ei^dera. These, however, are refinements, and one can seldom say they are absolutely indispensable. The great change of coming to Eui'ope is the most important one, and it matters comparatively little, when there, where the patient reside, if he be placed in a comfortable home, vAih. all the advantages of niu'sing, feeding, and tending, such as only his 0"wti friends and relatives can give. The question will, sooner or later, arise as to the propriety of retui'ning to India or other tropical abode, and the calls of service, of anticipated promotion, or of duty or business, and, above all, the res angasfti domi, urge him to go sooner than may be expedient, though he may feel, or think he feels, quite well. It is often a difficult question to answer. And you have to decide between the result of disappointment, mental depression, anxiety, or the needs of the service, on one hand, and that of a certain still existing state of disease. LECTURE in. 127 and the ultimate welfare of your patient, on the other. It becomes a question of the choice of evils — how much may a man risk ; how much may you sanction ? I advise you not to consent whilst any symptom of dysentery remains, nor until some time after the bowels have resumed their normal action, and all pain, tenderness, thickening, and irritability of the colon or rectum have passed away. There are cases where it may be necessary to give a modified assent, but if so, it must be coupled with the strictest caution as to the risks and the necessity for doing all that is possible to obviate them. I have known men come and go between England and India, suffering fi'om chronic dysenterj^, and recover at last ; but I have more frequently known the contrary. It is our plain duty in advising, to make health the first consideration. If the patient be a free agent he must exercise his own dis- cretion as to how he deals with your advice ; but never leave him in doubt as to your opinion. I would again insist that the advantages of change of climate in this disease are inestimable, and, if combined with careful living, far outweigh all else. Tropical Diarrhcea. I pass on to the subject of diarrhoea, especially that form of it seen in old residents of India and tropical climates, in this country. It is to this I wish especially to ask your attention, for time will not permit me to dwell at length on other forms and phases of the disease. Dcjinifwn. — The definition that may be given of dian-hoea is —a discharge of fluid or semi-fluid excreta, serum, mucus, secretions, and the natm-al contents from the bowels. Though unattended, as a general iiile, with tenesmus or much griping, there is increased peristaltic action and secretion, and hTirrying on of fluid na.tiu'ally secreted but not re-absorbed. The causes are, irritation of various kinds — certain ai-ficles of food, drink, drugs, poisons, acrid secretions ; mental emotions ; sudden exposiu'e to extreme heat or cold ; morbid conditions of the mucous and follicular structures of the intes- 128 TROPICAL DYSENTERY AND DIARRH(EA. tines consequent on the continued operation of the above- named or other causes ; diseases, such as typhoid, dysentery, cholera, hepatic disease, and others ; miasmata of decom- posing organic matter, alcohol, malarial poisoning, cachexia, or a state of general debility and tissue-degeneration of a fatty or lardaceous character, involving the intestinal tube mth other tissues in general atrophy. Etiologij. — In considering the causes of tropical diarrhoea, ■we must refer to those already mentioned as giving rise to dysentery ; for it is difficult to draw any line of differentia- tion between the diseases ; and where official retiirns are obscm'e in this respect it may, no doubt, be ascribed to the uncertaint}^ of diagnosis. So much is this the case, that, in the General Civil Eetmns, dysentery and diarrhoea are not separated. Dian'hoea is a symptom of disease rather than a disease itself. It may depend on several causes : — 1st. On an effort to rid the intestine of offending ingesta, whether of food, di'ink, dnigs, poisons, entozoa, acrid secre- tions, or the like. 2nd. On hepatic and splenic disease, or derangement of these functions and portal congestion ; on structmval change or functional distm-bance in the abdominal \'iscera and mucous membrane and follicles of the intestines. 3rd. On a condition of general disease, when it is elimina- tive of morbific matter in the blood, as in septicaemia, renal disease, gout, fevers, dysentery, typhoid, cholera, tuberculosis, cancer, scurvy, ansemia. 4th. On the re-absorption into the blood of excretions and secretions, the suppression of natiu'al discharges, when it is vicarious. 5th. On exposure to malarial and climatic influences, miasmata of various kinds, especially of decomposing foetid organic matters, alcoholic intemperance, foul air and gases, sudden alternations of heat and cold, of diy or moist aii'. Gth. On mental emotions, such as fear, anxiety, anticipa- tion, when it is reflex. 7th. And it may be the result of degeneration and atrophy IJXTUKE III. 1"J9 of the tissues generally, but of the bowel iu particular, as a consequence of starvation or of malarial cachexia, when it is wasting and chronic. A severe and dangerous form of diarrhoea is described as being due to the presence of bacteria {mycoais intestinaUs) by von Recklinghausen, Waldeyer, Yeo, and others, in which violent diarrhoea and vomiting were rapidly followed by collapse and death, attended by the speedy development of this organism in the stomach and intestines, causing a catar- rhal condition of the mucous membrane of those organs, con- gestion of the lungs, oedema of the areolar tissue of the mediastina, under the peritoneum, and of the intestines, with necrotic sloughs in the bowels, and infarction of the mesenteric glands due to embolism by those schyzo-mycetes — the disease and the consequent diarrhoea being a form of anthrax or malignant pustule in the intestines. With respect to micro-organisms in dysentery and diarrhoea, Dr. McConnell writes to me, especially as regards dysentery : — " These are to be seen in abundance in most cases where the disease has advanced to the stage of sloughing or ulcera- tion ; not only in the substance of the sloughs before being detached, but also iu the yet living mucous tissue in the neighbourhood of the sloughs, and at the margins and bases of the ulcers. This, however, is quite a different thing to attributing the disease, as some have lately done, to the presence of these organisms. On the contrary, I am inclined to believe that their presence denotes nothing more, probably, than that the parts affected are undergoing devitalization, and that just as in gangrene, erysipelas, extravasation of mine, etc., micro-organisms are to be found in abundance in the tissues becoming destroyed, so in dysentery, their presence is merely indicative of the same or a similar change, and has nothing specific in it." I remember a severe outbreak of diarrhoea among some Greek famihes in Calcutta that occurred several years ago, and which was traced to an acarus infecting some new diy caviare, recently imported from Novgorod. It had not been observed before by these gentlemen, in an article of diet l-iO rnoi'RAl. DYSKNTKHY AND DIAIUUKEA. with which they are familiar, and they were much im- pressed when shown the insect under the microscope. It was suggested that the symptoms might hav.e been due to a poisonous fungoid growth, some microphyte, but none could be found. The diarrhoea ceased when the caviare containing the acarus was discontinued. Having regard to these causes, a certain classification of the disease, which answers well enough for practical purposes, may be stated in the following terms : — Fteculent diarrhoea, the result of the presence of certain irritating matters in the pruiue vue, removed with removal of the cause. Congestive or inflammatory, due to continuance of irrita- tion, or catarrhal conditions thereby induced, or to constitu- tional causes. Checked action of skin, or miasmata, when the mucous surface, villi, and follicles of the intestine may be impli- cated. There maj^ be inflammation or even ulceration, and serous, mucous, or fibrinous and flaky dischoTges mixed with the fi?ecal matter, accompanied by pain, griping, and even blood ; apt to pass into dj^sentery, joerhaps is dysentery from the commencement. Though, like the ordinary acute dysentery, these cases are generally amenable to early treat- ment, they may pass into a chronic stage. In India or the tropics they so closely i^semble dysentery, if they are not identical with it, that they may be called either dysentery or diarrhoea. Then there is the bilious diarrhoea, the autumnal or summer diarrhoea, the so-called sporadic cholera, which sets in with great violence in India, and may so exhaust the patient by the loss of serum which accompanies or follows the expulsion of the ingesta, and bilious and other secretions, that symptoms of collapse, and the other conditions peculiar to true cholera, such as cramp, suppression of urine, great thirst, may occm*. It may occur in this country, and often causes great debility. The conditions are indeed very like, if not identical with, those of true cholera. Of course, I do not say the causes are identical, for I confess I am ignorant of the LECTURE III. I'^l precise nature of either ; but the appearance of true cholera is frequently heralded bj cases of this kind ; and it is often a great source of anxiety in India, when such an attack of diarrhcBa does make its appearance, lest it should pass into real cholera. Happily, if it has not this tendency, it is readily con- trolled; but those who have been in cholera camps and regions, and have had to deal with outbreaks of cholera, know the vital importance of checking looseness by some sedative and astringent at the outset, feeling well assured that by so doing they may in many cases prevent the sufferer from passing into the dangerous condition that is foreshadowed by the diarrhoea. Doubtless, in many cases astringent and sedative remedies are given, when a dose of castor oil or Grregory's powder would have been more to the pui^pose, but that is an error easily rectified ; whereas the passing of a diarrhoea into cholera is a very serious matter, and may prove fatal if not checked at the outset. Lastly, there is the chronic diarrhoea, depending on visceral changes due to constitutional causes and defective nutrition. As to the nature of the diarrhoea that prevails in India and the tropics, I may say generally that all the forms of diarrhoea observable in Europe may be seen there, and are amenable to the same methods of treatment, which have for their object the removal of peccant matters, the allaying of iiTitation and congestion or inflammation, and the treatment of the consti- tutional conditions that may be the cause of the evil. Europeans and natives suffer in India from indiscretion or intemperance in food and di'ink, and from changes of tempera- ture, etc. — in short, from whatever causes the disease elsewhere ; and in some instances, no doubt, these are intensified by climatic conditions. It is of diarrhoea due to tropical and malarious influences — that which results from the consequent debility and cachexia induced by these conditions — that I wish to speak. In my first lecture I said that diarrhoea is the cause of considerable mortality in India, both among Europeans and K 2 182 TKOPICAI. DYSENTKKY AND DIARRHCEA. natives, the following being the prevalence or death- rates : — Of different classes. Strength. Admitted. Died. European Army ! 56,475 3,972 . 4 ■women 5,170 299 • 8 children 10,423 1,033 149 Native Army 117,272 4,747 I 112 Gaol population 127,914 12,998 ! 1,865 p. ., , ,. J 2^ per 1,000, among 182 millions of people, of L> vil popu a ion | diarrhoea and dysentery. I told you, also, that there was some uncertainty as to the precise nature of the cases appearing under the difPerent headings in the returns, especially as regards the civil jjopu- lation, where it is impossible to have the same accurac}' of registration as in the army or gaols, considering the immensity of the population and the comparatively small means of oarrj'ing it out ; and that in the retiunis, dysenterj^ and diarrhoea are classed together imder one head, " Bowel- Complaints " ; still, the information we derive from them, and from exjoerienee, shows that diarrhoea is frequent and sometimes fatal, its prevalence and fatality being closely related to climatic and local causes, whilst defective food, impm-e water, and insanitary conditions of lining, are largely concerned in producing it. Many cases, were it possible to trace theii- history and termination, might be transferred to the columns of cholera or dysentery ; whilst a large j^roportion, in some years at least, would be traced either to the dii'ect or secondary effects of famine, which cause degeneration of the intestine and digestive organs ; and these results are not only to be seen in the immediate area where the famine prevailed, but in remoter districts, where the people have suffered plow starvation, fi-om the diminution of their natural food supplies, caused by the exportation of grain to meet the wants in the actual famine districts. The subject has been most carefulh^ investigated in all its aspects, and reported on, by medical and other officers ; whdst the natm-e of the pathological processes set up b}- ckronic starvation, especially in reference to the resulting bowel-complaint, dysentery, and LECTURE III. 133. diarrhoea, for you may call it either, as the diseases are often nearly allied to each other, has been exhaustively examined by Dr. D. D. Cuningham, who has given a most valuable account of the pathological changes of a fatty or lardaceous and atrophic nature that occur in the mucous sui'faces and follicles of the pn'mce rice, as well as in the tissues generally ; and which show not only the effects of complete starvation, but that a process of chronic starvation and inanition, caused by insufficient food, induces degenerative changes in the intestines that render them unfit for the functions of nutrition ; and that the mortality induced by these secondary causes is necessarily great. The lesson to be derived from this is the importance of providing the population with sufficient food to prevent the tissue-changes that in chronic starvation are inevitable, and which in the end prove so fatal. The mortality, indeed, has been great, and a considerable portion of it was due to bowel-complaint. This, to a certain extent, may be regarded as an excejjtional cause of diarrhoea, but the experience it affords suggests the following considera- tions : — First, how to prevent these degenerative changes in the intestines ; second, how far they may proceed without proving fatal ; third, what can be done to assist natm-e in repairing the mischief when it has occurred? Though it is not diarrhoea caused by famine that I propose to describe, yet in many cases it is as nearly as possible the same disease ; for though the patient may not have been famished into a state of fatty or lardaceous degeneration of his stomach and intestines, yet, if he have been brought into that condition by climatic or other causes, he is practically as much starved as though he had been in an Orissa, Bengal, or Madras famine ; and he is in as much danger of dying from inanition, because his intestines have lost, from the same form of degeneration, the power of performing their natural func- tions. Such, indeed, is the condition of many of the cases of chronic diarrhoea in old Indians and other tropical residents that come imder our observation here. Chronic diai'rhcea, diarrhoea alba or white flux, is one of the most important, as it is a most dangerous, form of 134 TROPICAL DYSENTKKY AND DIARRHCEA. the disease. All diaiTliooas may become chronic, and when they do so, induce exhaustion, antemia, and idtimately tissue- degeneration ; but it is in the peeidiar form to which I now allude that the worst symptoms are manifested, and that a dangerous and protracted state of disease results. It is insidious and slow in its progress, but surely wasting in its effects ; and when protracted beyond a certain stage, it is fatal, owing to the irreparable state of degeneration of the intestinal mucous surface and glands, and the consequent inability to absorb nourishment. Death results from slow inanition, simply because the channels for the admission of nutritive material are destroyed. This form of diarrhoea has been described by Annesley, Twining, Martin, Groodeve, and others, especially by Mr. A. Grrant, in the Indian Annals of Medicine, in one of the most interesting of many important papers on tropical disease pub- lished in that valuable journal. It is commonly known in India as " hill-diarrhoea," because it is apt to appear in some of the Bengal hill-stations, where malaria, atmospheric changes, and very probably water, are instrumental in producing it in persons who have suffered more or less from the debihtating influences of the plains, though by no means confined to them, for it occurs sometimes to recent arrivals, and to those who do not seem to have suffered otherwise from the effects of climate; still it must be regarded, I think, as a climatic disease. The hill-diarrhoea and the white flux of other parts of India are only modifications of the same disease, and in their patho- logy and symptoms so much alike that I regard them as identical. It is frequently seen in this country, j)erhaps as often as in India, for it is so well understood that removal from the climate or site where it was contracted is necessary, that those who suffer from it are generally sent home. There is, as I before remarked, a close resemblance of this disease with some forms of chronic dysentery. Sir E. Martin has well said — "Although chronic diarrhoea generally follows on previous tropical disease, I have seen it affect persons on their return to England, who. LECTIIRK III. l'}-> during their residence in India, had never suffered from any of the diseases of that country. The health of such patients, however, had been enfeebled, and they were thus rendered susceptible to the influence of cold or damp, or, what is always more injurious to the retrained Indian, to both con- joined. The returning Indian is often seized with diarrhoea from exposure to cold on board ship, especially if exposed to the spring easterly winds. The cold of the English winter and spring proves very adverse to the cure of this disease, and I have constantly to send patients suffering from it to the sheltered places on the coast, as Hastings, Bournemouth, Veutnor. Fatigue is almost as injurious as cold. An officer sent to Bournemouth walked beyond his powers. The residt was a relapse that nearly proved fatal." I may add that persons who come home from India suffering from general debility, from climatic cachexia, " too long in India," attended with hepatic derangement, and a congested portal system, are liable to be troubled with diarrhoea of an irregidar character, generally most troublesome in the morn- ings, rendering the patient unable to go out or undertake anything before eleven or twelve o'clock — or after taking food, or from fatigue of any kind, or any indiscretion in diet or diink, or exposure to cold or damp. Such are benefited from relieving the congested portal system by the aid of saline laxatives, careful well-regulated diet, attention to clothing, and, above all, hy the good effects of change of climate. These cases are sometimes obstinate enough, most so in those who have had long residence in India, and especially if there be any hepatic or splenic complication, or any vestige of former dysentery. They, however, are not of so grave a nature as the chronic white tropical diarrhoea, and recover more quickly, betokening rather functional disorder and congestion than structural and degenerative changes in tlie viscera and the mucous surface of the bowels. There may, of com'se, be some atrophic change, but this will soon be made out by the character of the excreta and the general progress of the symptoms. I'^C) TROPIC Al, DYSENTKIIY AND DIARRHCEA, I pass over other forms of diarrhoea with the mere mention that I hare made of them, as subjects on which I could have little to say that would interest you. Let me now say a few words on the s_)Tnptomatology of this special form of chronic diarrhoea, for it expresses all of general importance regarding tropical chronic diarrhoea. Symptomatology. — This is one of the most troublesome, tedious, and often dangerous forms of dian-hoea, often in- tractable and obstinate in character as it is exhausting in its effects. Though generally seen in those who have spent many years in hot climates, it occasionally occurs in others who have been there but a short time, and is known as " diarrhoea alba," or white flux — so called from the grey, whitish, light, or clay-coloured evacuations, which are frequent, copious, fluid, or semi-fluid, often frothy, and occasionally lienteric, especially after any indiscretion in diet ; or mixed with mucus tinged with blood, when any fresh soiu-ce of enteric irritation or congestion may have occiu'red.. Its origin is often insidious, commencing mth simple looseness of the bowels, little or no pain, and producing rather a feeling of relief than of suffering ; and not until the subject of it finds he is losing flesh, strength, and energy, does he realize the serious nature of the complaint. It seems to be the result of climatic influences in which, probably, malaria is concerned, and is due rather to a general derange- ment of the hepatic, splenic, and gastro-intestinal functions and to atrophy of the mucous membrane, its villi and glands, than to the usual ii-ritant or eliminative causes of diarrhoea. The appearance of the dejections is suggestive of deflcient or altered bile ; but this probably may be accounted for by the general state of anaemia rather than by any actual disease of the liver itself. It is onlj^ as the disease progresses that the pale colour of the excretions becomes so marked, for in the outset they resemble those of ordinary diarrhoea. The balance between exhalation and absorption seems to be disturbed, and much of the fluid which, in the natural osmotic circulation of inte'^tinal fluids, would be re-abporbed, ie huirifd on and LECTURE III. 137 expelled ; the absorption of nutrient matter is interfered with, and wasting and degeneration result, as may be seen in the attenuated and exhausted frames and atrophied bowels of those who have died from the disease. The appearance of persons suffering from this disease is characteristic. They are pale and emaciated, with loose, dry, flaccid, flabby skin, which in later stages becomes discoloured as by chloasma or Addison's disease. The fat disappears ; the eyes are pearly ; the lips and conjunctivse are blanched ; the tongue is dry and smooth, and in advanced stages it appears contracted and shrunk, its papillae are obliterated, the surface is red, glazed, and dry, at times its edges are excoriated, and the buccal mucous membrane, the seat of aphthous spots or epithelial proliferation, and so tender and sensitive as to be intolerant of wine or any substance or fluid in the least pungent or stimulating. The earlier phases are often characterized by some evidence of malarious poisoning, such as fever, neuralgia, or myalgia. Distension of the abdomen, especially after food ; dyspepsia ; irritability of the bowels, which are provoked by anything taken into the stomach to expel their contents ; general languor and debility, mental and physical, increase, until all exertion is difficult and distasteful. As the diarrhoea gradually increases, these symptoms may, to a certain extent, be mitigated, and the patient think himself better; but as it insidiously progresses, the strength fails, and sooner or later he finds himself compelled to give up work and seek recovery in change of climate. There is at last extreme ansemia ; dropsical effusions take place into the areolar tissue of the lower extremities. A very similar, perhaps identical, form of disease is known in some of the hill-stations of India as " hill-diarrhoea," and has been well described by Twining, A. Grrant, E. Groodeve, and other Indian medical officers. It often proves intractable, and even fatal. Occasionally, perhaps, it is the resiilt of injudicious selection of climate after recovery from disease. Many of the cases trace their origin to a hill-station in India, M'here the sufferer had gone in search of health which he 188 rHoricAi, dysentery and uiAKiuiaiA. was more likely to have recovered hy a sea-voyage or a visit to Europe. This chronic white diarrhoea appears to be as much the residt of general degeneration of all, as a special disease of certain organs. Ansemia, the result of inanition, imperfect absorption, and waste of the nutrient material, is the most marked symptom during life. Examination of the bodies of those who have succumbed to the disease shows that the wasting which is so marked in the body generally, has ex- tended to the viscera themselves. When death has occuiTed at an early period, from the intercurrence of other disease, the intestines are found contracted, with the mucous lining thickened and congested, even ulcerated ; but when death has occurred later, the coats of the bowel are found to be attenuated and diaphanous, the seat of fatty or lardaceous degeneration, frequently ulceration in both ileum and colon, the glandular structures and the mesenteric glands atrophied and degenerated, the mesentery itself wasted. The liver is shrunken, pale, and contracted ; the spleen and kidneys often in a similar condition. There may be, in certain instances, enlargement of liver and spleen ; but in ordinary cases of the disease there is no such complication. Though chronic diarrhoea is frequentl}' the result of general degeneration of health from malarious cachexia, it is not always so, and other sources of enteric irritation or of elimina- tion, caused by disease or disordered condition of the hver, spleen, or kidneys, or chronic dysentery, may give rise to it ; but it is the simpler, though not less serious, form that I now speak of, and for the management of which I shall presently offer a few suggestions. Pathology and Morbid Anatomy. — The opportunities of studying the morbid changes that take place in ordinary examples of the disease are not fi-equent, as in so many cases where death occurs it is under circimistances where post- mortem examinations are not readily obtained ; the invalids who succumb being frequently persons who die in their own homes, and when there is seldom opportunity of obtaining permission to make an autopsy. In some cases, however. LECTURE IIT. 139 as in hospitals, infirmaries, etc., it does happen that an investigation can be made, and I ^dll describe the patho- logical changes that generally may be observed. It has long been known that the disease is associated with chronic disease of the liver. Annesley, Twining, and others have described it. Martin, Grant, Goodeve, and others have pointed out its connexion with visceral disease and wasting of the tissues, with general ansemia ; whilst post-mortem examinations have demonstrated the attenuated, blanched, and atrophied state of the mucous membrane and follicles of the intestines. E. Goodeve gave an account of the state of the mucous membrane and glands, showing that in some cases they were in a state of amyloid degeneration ; this I also pointed out in a paper written thi^ee or four years ago. He says that " in children d}dng of the inflammatory form of diarrhoea there may be some swelling of the follicles and Peyer's patches, but in the chronic forms there may not be much surface-change, except in the inflammatory varieties. There may be traces of redness in patches, ulceration of the glandular structures in various states of repair, greyness of portions of the mucous membrane, black or dark margins to the ulcerated tissues or healed ulcers, and puckering and contraction. In some chronic diarrhoeas, especially those with the white flux, in spite of the long duration of the disease, little or no change of the mucous surface is to be found. There is great thinning of all the coats of the small intestines, so that they are quite translucent, and there is doubtless atrophy of the glandular tissues." " When these patients have had dysenteric symptoms towards the close of life, ulceration or sloughing of portions of the colon may be found. The mesenteric glands are generally enlarged and hardened in chronic diarrhoeas, but especially in the white flux. The liver is not necessarily altered, even in the white diarrhoea ; bvit it has been found flaccid, anaemic, and small or of natural size, but without any decided morbid appearance. It occasionally presents patches of fatty degeneration, but this is not peculiar to diarrhoea." — (Article, "Diarrhoea," in " Eeynolds' System of Medicine," vol. i., pp. 96, 97.) 140 THOPKAl, DYSENTERY AND DIARKIICEA. In regard to the question of amyloid or lardaceous degene- ration, Dr. McConnell, of Calcutta, who has many opportuni- ties of investigating pathological questions of this nature, and who occupies ■s^dth great credit the chair of Patliology in the Medical School of Calcutta, in reply to a question put by me to him on this subject, ^\T.-ites : — " Amyloid degeneration of the bowel, as far as my experience goes, is very rare among the natives of this country. I do between 200 and 300 post- mortems here yearly, and I think I find about one in 100 cases of amyloid degeneration of any organ or organs of the body. I really do not think it is commoner than that, and of all parts the intestines are least frequently affected." He recognizes the acciu'acy of the account given by Dr. D. D. Cuningham of the morbid anatomy and structure of the intestines of the sufferers fi'om diarrhoea and dysentery in the Indian famines — a condition probably similar to that of other chronic diaiThoeas. We are much indebted to Professor Aitken for the very definite and clear account he has given of lardaceous degene- ration in the intestines in certain forms of diarrhoea. He says : — " Lardaceous disease of the intestines comes next in frequency to that of liver, spleen, and kidney," and " involves the ai-terial capillaries of the villi and surrounding networks of mucous and sub-mucous tissues, it progressively involves the \alli, mucous, and sub-mucous capillaries, infiltration around the solitary glands, and degeneration of the vessels surrounding the Peyer's glands." He has repeatedly met "wdth it, in the cases of soldiers at Netley, where it involved the whole tract from mouth to anus. Ansemia of the mucous membrane, vnth. a peculiar glistening or shining aspect of its sui'face, are the most characteristic signs of the lesion, " otherwise there are no outward signs to attract attention." The application of the iodine test is necessary to detect it. Aitken refers to Vii'chow's account of this condition, and says : " Virchow has known the villi to drop off, and the intestine to be bare of villi." Such, I beheve, Avould not unfi-equently be found the case Avhen death has resulted fi'om 1,ECILRE HI. 141 advanced stages of chronic diarrhoea. "Sometimes the villi are changed into lurdaceous or albuminoid material." Ulcers form ; Peyer's patches and solitary glands are enlarged at one time ; ultimately they are destroyed by a " granulo-fatty disintegration." The whole tissues, in fact, become degenerate. Dr. Grrainger Stewart has said that " haemorrhage from the bowels or stomach may occur in the secondary stage of this condition. There is neither colic nor pain, and the haemor- rhage may occiu"- independently of any ulceration of the mucous membrane, but as there is so frequently ulceration it may be the cause when hajmorrhage does occm\" The tropical diarrhoea with which I am immediately concerned no doubt partakes largeh', in the character of its intestinal lesions, with the morbid degeneration so elaborately described by the above-named authorities. But I woidd refer you to the very elaborate and careful examination in the Eeport by Dr. D. D. Cuningham * on the diarrhoea and dysentery in the famine districts, in which he shows how the degenerative and structural changes involve the intestine and other viscera. And it is im- possible, I think, not to see the bearing of those observa- tions on the pathology and therapeutics of chronic bowel- complaint generally, whether it be dysentery or diarrhoea. The following is an abstract of the observations made in this valuable Report : — The mucous membrane of stomach, jejunum, and duo- denum was white, pidpy, soft, and bloodless ; some traces of congestion, marks of disintegration, in jejunum ; dis- appearance of epithelial coat ; pigmentation and atrophy of sub-epithelial areolar tissue. Mucous membrane of ileum presented more evident signs of change ; bloodless generally, but here and there patches of congestion ; epithelial coat disorganized or absent, and sub-epithelial tissues affected. Solitary glands either very few or almost entirely absent, Peyer's patches were an empty network of elevations, sur- * Fourteenth Annual Report of the Sanitary Commissioner with the Government of India, 1877. 142 TKOl'lCAl, DYSKNTKRV AND IJIARRIKKA. rounded by slightly elevated ridges ; the adenoid tissue virtually absent ; surface smooth ; villi almost unrecog- nizable. Muscular coat, covered only by a thin membranous investment, seemed to form the inner lining of the tube ; most pronounced over lower half or two-thirds of ileum. Microscopical examination showed that the epithelium, where present, contained much fat, the cells including large quantities of oil granules. In the vicinity of denuded areas, vestiges of cells and free granular matter present. The sub-epithelial tissue showed evidence of similar changes ; the nuclei granular and oily. This may, to some extent, have caused the appearance of pigmentation that was observed, but there was a certain proportion of pigment granules. It is impossible to say whether this deposit of pigment in the mucous membrane is essentially connected with the morbid processes. It is a phenomenon of other wasting diseases, and is generally ascribed to antecedent minute extravasations of blood, but it may be due to degenerative processes. In the more advanced stages of atrophy of the mucous membrane the nuclear elements in the villi appeared to be almost entirely absent, and the villi were represented by abortive processes containing granular matter. The mucous membrane of the large intestine was also generally aneemic — white, but mottled pink here and there, and its texture very soft. In some cases there was thicken- ing. Besides the general softening there was evidence of loss of substance in some places. These patches in certain instances might be called ulcers, in others they seemed to be merely the result of disintegration and atrophy. In such instances there was no evidence of congestion, and the colic lymphatic glands were pale and inconspicuous. The appearances presented by the mucous membrane were some- times more like those of dysentery. In one case this was decidedly so. There was great thickening of the gut, the mucous membrane was broken up into hard rough masses of purple and green colour, distinct ulceration had occuiTed, LKCTURK Iir. 14;') aud there was considerable congestion, whilst the lymphatic glands were turgid and deep-piirple-coloiu'ed. Fatal cases of the so-called famine dysentery may occur in which no true dysenteric processes, as ordinarily under- stood, are present. The essential process appears to be the same as that affecting the small intestines, but it may be complicated in various degrees by the supervention of true dysenteric changes. Does it not show how nearly the two diseases are allied — perhaps only different manifestations of the same ? The liver was small, pale, yellowish, fatty- looking ; in some the cells were healthy, in others full of fat granules. Grall-bladder half full of bile ; it was healthy in those where the cells were healthy ; in the fatty it was pale, yellow, and very thick. The spleen was small and finn, in most cases conspicuously so. In some cases it appeared to present little save a dense contracted mass of stroma, in a white shrivelled capsule. Kidneys, as a rule, pale and ansemic ; in some fatty degeneration of the epithelium. Pancreas, normal in some ; in others, substance seemed as though it were opened out, the lobules widely separated. Brain slightly anaemic. The general result of the entire series of observations was to show that the diseased conditions were specially characterized by extreme general ansemia and destructive processes affecting the mucous membrane of the intestinal canal. A word or two on the diagnosis between dysentery and diarrhoea, which is often difficult. Diarrhoeas are generally free from mucus and straining in the early stages. In chronic dysentery there is blood and mucus more frequently than in diarrhoea, though where there is ulceration in diarrhoea there may be blood, and it is difficult to determine which to call it. It is, after all, not a matter of much practical importance ; and, as I have already said, the conditions are so similar that they are often confounded. In the earlier stages there is no difficult}^ ; in the later the treatment of both is mucli tlie same. I have just received a paper on a form of chronic diarrhoea, by Dr. P. Manson, known in China and in Java b}- the name 144 TROPICAL DYSKNTEKV AM) DIA K HIKEA. of Sprue ; it apj)ears to be the same disease as that I have been describing, or a variety of it. He describes it as a result of inflammation of the alimentary nmcous membrane, with anaemia and general atrophy ; and ascribes it to the influences of a tropical climate on the European constitution, especially after long residence in the East. This, like all Dr. Manson's writings, is an interesting and ^-aluable contribution on the subject of which it treats. Treatment. — I shall confine what I have to say on the subject of treatment, to that of chronic diarrhoea ; for it is needless that I should occupy your time by describing that of the ordinary forms. I would merely again refer to the importance of checking all forms of diarrhoea during cholera seasons, or when that disease is imminent. The commencement of chronic diarrhoea is often insidious, and the disease gains ground before radical measui'es are resorted to for its removal. In the cases that come under notice at home, the most essential step towards recovery has been taken by retm'ning to Europe ; but there remains much to be done to fm-ther the improvement, which has probably advanced considerably during the sea- voyage. The successful treatment of chronic diarrhoea depends very much on the patient's resolution and perseverance in carrying out the instructions he receives. Diet is the most important element in it, and this must be strietlj^ regidated ; all irri- tating or indigestible and solid food must be at first entirely prohibited, and only that which is most easily assimilated allowed. Milk, alone or dihited with about one-fom-th or one-third part of lime-water, given in small quantities and at frequent intervals, say a wineglassful or small tumblerful every second or third hour, in some cases more frequently, will generally be found to answer, and may be continued for a long time, to the exclusion of all other food, ^vith great advantage. Milk undihited will not always agree, as may be seen by its causing irritation, frequency of action, and the passage of undigested caseine ; but it is quite sufil- cient for all purposes of nutrition, and by the time the patient finds that he is taking three to four quarts a day, he I.KCTURK III. 140 will have realized that he obtains from it all that is needed to support health and strength. At first he may lose weight, but soon regains and increases it. Beef-tea, raw beef-juice, or other plain animal broth, fi'ee from extraneous matters ; a raw egg beaten up with milk, to which a teaspoonful of brandy may be added, will sometimes be tolerated ; arrow- root, tapioca, or other plain farinaceous food Avill sometimes, but not alwaj's, ansT\'er — certainly not at fu'st. Tea and coffee, as a general nde, disagree, and should be avoided. Stimidants, especially for those who have long been habitu- ated to theii' use, may be needed ; the best are a little whisky or brandy diluted with Vals or Vichy or potash water ; but these should be laid aside if they increase the action of the bowels. A little good port wine may be tried ; but, as a general ride, I find all ^Ndnes unsuitable. Regularity in the times of administration and in the quantity of noimshment given is most essential. The greatest care should be taken not to give too much of an}i;hing at a time, and at once to discontinue wliatever appears to disagree. It is necessary that the patient shoidd be kept Avarm, and at an equable temperature day and night. The body shoidd be covered vdth. flannel or woollen next the sldn, and a flannel bandage should surround the abdomen. Chills and damp are especially to be avoided, for exposiu'e to them may seriously aggravate the mischief. Dming cold weather the patient should not leave the house. As the condition improves, this disci2:)line may be relaxed, and gradually the patient may be allowed to go out and take moderate exercise ; but until considerable improvement has taken place he shoidd be extremely carefid in this respect. It is desii'able to keep much in the recumbent posture, as mechanical rest for the bowels is a most important element in the treatment. It might be well, if possible, for the patient to reside dming the cold months of the year in some of the milder and more sheltered paits of the country, and perhaps near the seaside of the south coast. The care, atten- tion, comforts, and good food of a home, however, are more important than any benefit to be gained fi-oni suoli changes I, 146 TllOPICAL DYSENTERY AND DIARKHCEA. as may be derived from removal to different localities in the United Kingdom, where home advantages might be wanting. As the diarrhcea diminishes, the condition of the excreta improves, and strength is regained, the diet may be more varied, and out-of-door exercise more freely taken. But long after recovery is apparently complete, the greatest care must be taken to avoid errors in diet, over-fatigue, or exposure to extremes of temperature, or a relapse may take place. It is desii-able that the stay in Europe should be prolonged, espe- cially after recovery from severe attacks, beyond one Indian hot season at least, and it may be necessary to defer return to India for another year. Drugs will do little good if strict dietetic and hygienic rules are not most carefully and continuously observed. Under tlie impression — derived chiefly from the appearance of the evacuations — that the liver is mainly at faidt, it is sometimes deemed expedient to administer cholagogues or alteratives. This, I think, is unnecessary, as there is not sufficient ground for supposing that the liver is specially at fault. The chief indication is to restore the healthy fimctions of the bowel by giving it rest, to promote absorption, and delay the exj^idsion of its contents. This we may hope to effect by introducing only bland, unirritating, and nutrient fluids, by allaying irritation and checking excited action, and by administering such remedies as may tend to improve the general health. To allay the irritable state of the bowels, the compoimd ipecacuanha powder, in combination with bismuth, quinine, and alkalies, may pro\'e useful ; where the motions are fluid, copious, and frequent, tannin or gallic acid may be given in combination ^dth Dover's powder. Sulphate of copper with opiimi has been recommended. Dilute nitric and muriatic acids in combination \\iih. opium have been foimd beneficial where other remedies have failed. Nitrate of silver is some- times given, hwi I have not found it to produce very satis- factory results. Counter-irritation over the abdomen by sinapisms or turpentine stupes is useful. Opiate and small demulcent LKf'TIIRE III. 147 injections are often efficacious in allaying the irritability of the bowel and giving rest ; hypodermic injection of morphia may be tried, if opiates do not agree, but I have not found it necessary to resort to them. Opiates are sometimes objected to on account of their interference with the secretions ; but this is, I believe, a groundless objection. The colour of the evacuations need not prevent their use, and the rest and quiet they give may be of importance. Mucilaginous decoctions or infusions, such as those prepared from the fresh bael fruit, or from the issofgool {Plan f ago Isphagoola), the seeds of which are often given with, good effect by tlie natives of India for the sake of the mucilaginous envelope, solution of gum, water ari'owroot, etc., maybe beneficial for their soothing and nutrient properties. The preparations of iron are often useful in controlling the diaiThoea and in improving the condition of the blood. The iron alum, in doses of four or five grains, the citrate or the potas. tart, of iron, in three to five-grain doses, in some aromatic water, two or three times a day, are good forms in which it may be given ; and it may, viewing the malarious origin of so many of the cases, be well to combine quinine with the ii'ou. Two or three grains of quinine with tkree or four of Dover's powder, and three or four of bismuth, may be given. In the earlier stages of the disease, where there is hepatic and portal congestion, ipecacuanha in large doses — ten to twenty grains — ^may cut short the state which would have passed into diarrhoea. This, however, is quite inappli- cable to the disease in its more developed stages. I have found some cases which were aggravated by a state of portal con- gestion, improve rapidly after a few doses of a sahne aperient. As recovery progresses, preparations of quinine, ii'on, and other tonics are beneficial. A visit to some of the Continental health-resorts may be of advantage in expediting recovery, not only for the sake of the waters, chalybeate or others, but for that important element in recovery from nearly all chronic diseases, " change," and for the regulated and physiologically correct life, and the mental tone, imparted by the determina- tion to 2:et well. 148 TFIOPK Al, DYSFA'TKltY AM) DTAKKIIiKA. The use of drags will Le modified b}- the peculiar cireuni- stances of each ease, but I think that, generally, the plan I have suggested will prove successful in cases that have not advanced too far. AVhere emaciation has made great pro- gress, where the tongue is always red, smooth, and glazed, the mouth dry or aphthous, the diarrhoea constant, and the exhaustion great, one cannot but feel great anxiety and uncertainty as to the result, though it is seldom necessary to declare a case hopeless. The diarrhoea may disappear in this condition, giving a delusive appearance of improvement, whicli is not unfi-equently the precursor of death. Happily, a number of chronic diarrhoea cases of the character I have been describing have a favoiu'able termination, and they are so in proportion to the care in which the patient adheres to tlie plan of treatment laid do-uTi for him ; and I would emphatically repeat that strict adherence to simple milk for a long period — it may be for months — ^will often prove of more value tlian medication of any kind. I would only add, in conclusion, that in these cases the fresh bael, taken early in the morning in the form of mix- tiu'e, or sherbet, as it is given in India, will often have good effect. A remedy that has often produced good results in India coidd hardly fail to do so here ; but of course it, like all other mere cb'ugs, is altogether of secondary importance to the dietetic and hygienic measiu'es I have tried to de- scribe. I will now relate the details of some cases illustrative of the diseases I have just been considering. Case 1. — Chroxic Dysentery. C. H., aged thirtj-; December 7th, 1880. Has been at Manilla since 1872, though away at times. Had dysentery and fever after six years of health. Hetimied to England in 1879. Went out again in 1880, but had to leave in tlu-ee weeks, with return of dysentery and diarrhcea. He is pallid, amemic, and emaciated. Passes blood and mucus, and loose LECTURE 111. 149 fseculencG. Tongue clean, not smooth. Bowel thickened. Functions otherwise healthy. Argent, nit. injection gr. ij. ad §j. Ipecac, gr. j., pulv. rhei gr. ij., pulv. hyd. gr. j. in pil. every fourth night. Warm clothing. To take only milk, or milk diluted with soda- or lime-water. Mist, belse, mane. December 14th. — Has followed the instructions as to diet closely. The only solids eaten in the first three or four days have been a little fish and a few small pieces of biscuit ; found that taking about a dessert-spoonful of whisky in a claret- glass of water, two or three times a day, almost put a stop to a slight feeling of nausea and faintness which at first was troublesome. For the first two days he had loose stools twice a day, accompanied by a little blood and mucus, but since then only one, the quantity of blood and mucus both de- creasing ; yesterday and to-day the former were entirely absent, and the mucus only in very small quantity. The stools for four days have been nearly quite formed, and the faeces much larger than any passed for more than two years. Since the second day has suffered from a constant pain in the pit of the stomach, like indigestion, or as if the stomach were filled with wind which refused to be expelled. The stomach is painfid on pressure. This he had often felt before, but found relief in taking food. The injection argent, nit. was used once, and it caused little pain, but the inconvenience of using it was so great that he discontinued it. He has had less irritation about the anus, and any pain he felt in the lower bowels has been evidently caused by flatulence. In weight he fell from 10 st. 5 lbs. to 10 st. 2 lbs. in twenty-four hours, and has remained stationary at that since ; still feels rather exhausted about five in the afternoon, but thinks not more so than when on ordinary diet. Has been walking two or three miles daily, but has not ridden. December 31st. — Is much better ; all symptoms of dian-hoea and dysentery have ceased. He is taking two to three quarts of milk daily, and no other food. January 6th, 1881. — Is feeling very well. Had no more dysenteric motions. There is still some thickening about sigmoid flexure of colon. Stools are fonned. To continue 150 TROPICAL DYSEXTERY AND DIARRHOEA. the bael every morning. May add a little solid food to the milk on which he has lived almost entirely lately. To take gr. iij. of potass, tart, of iron t^\dce a day. A few days later he -^Tote to ask permission to go to South America, apparently feeling qydte well. Permission granted, ■with caution as to diet. Case 2. — Chronic Dy'sextery, "with Enlarged Spleen. Dr. McConnell. R., Mahomedan, aged twenty-five, admitted into Medical College Hospital on April 23rd, 1879 ; died June 30th. Had been suffering from enlargement of spleen and intermittent fever for three months, with occasional attacks of dysentery. Emaciated ; skin dry and harsh ; conjunctivse ansemic ; tongue moist, coated with white fur ; pulse quick and feeble. No enlargement of liver, but the spleen descends nearly to umbilicus. For five days after admission the fever was dis- tinctly quotidian, and there was no bowel trouble. After the fifth day the temperatm'e fell to normal, and the patient began to improve in condition. On the sixteenth day after admission, dysentery set in with a reciurence of the old symptoms, and he now began to pass eight to ten stools in the twenty-four hours, the evacuations consisting of rosy mucus and blood. May 15th. — Eight stools in last twenty-four hours ; loose, bilious, and containing gelatinous mucus and blood. 30th. — Better ; only one stool during the last twenty-four hours, and pm^ely fseeulent. Continued well and slowly gaining strength until Jime 23rd, when another relapse of the dysentery occurred. From this time to death the disease was unabated and unchecked by treatment. Fourteen or more stools in the twenty-four hoiu'S, with rosy or shreddy mucus and blood. He died, quite exhausted and worn out, on June 30th. Treatment. — T^Tiile the fever lasted, cinchona alkaloids in seven- to ten-grain doses, with bismuth and soda, were pre- LECTURE HI. lOl scribed. When the dysenteric symptoms set in, twenty grains of pulv. ipecac, were given at bedtime, Dover's powder, soda and bismnth, each gr. v., t. d. Latterly, catechu and opium or koorchee mixture, anodyne enemata, lead and opium pill. Post-mortem Examination (July 1st, 1879 ; fifteen hours and a half after death). — Body greatly emaciated. Brain and membranes anoemic. Peritoneum healthy. Liver a little shrunken ; sm*f ace slightly rough ; substance mottled on section ; the interlobular tissue thickened ; the lobules prominent, and the hepatic cells composing them fatty in parts, in others darkly pigmented and ecchymosed. No re- action with iodine. Weight of liver 2 lbs. 4 ozs. Grall- bladder half full ; bile thin, of a turmeric-yellow colom-, and measures about half an ounce. Sj)leen enlarged ; cap- sule thick and opaque ; substance very dark and soft ; proper structure ahnost undistinguishable ; weight 1 lb. 2 ozs. Kidneys a little atrophied. Stomach small ; mucous mem- brane slightly corrugated, pale, and anaemic. The mucous membrane of the small intestine has a slate-grey colour in the duodenum and jejunimi. The ileum shows patches of recent vascularity. No affection of the glandular structures. The mucous membrane of the lai'ge intestine from the caecum to the anus exhibits dark, gunpowder-like pigmen- tation in smaller and larger patches — the sites evidently of old ulceration. Here and there the gut is puckered by fu-m cicatrices or ulcers partially healed. The ulcers are found chiefly on the descending colon, sigmoid flexure, and rectum. They are all small, superficial, with sharp-cut, punched-out edges, their margins siuTOunded by a ring of pigmentation,'their bases of rosy-pink colour and ecchymosed. They all possess a more or less indolent, weak, unhealthy character. The rectum shows serpiginous ulceration of the same type. The muscular coat of the bowel is thickened here, but throughout the rest of the intestine all the coats are thinned and atrophic. The mesenteric glands are all a Httle enlarged and hypersemic. The stomach contains about six ounces oE milky fluid, yellow-coloured from admixtiu'e with bile. In the small intestine about the same quantity 102 IKOl'KAL UV.SK-NTKRV AXl) DlAlUllia-lA . of offensive, clay-coloured fluid was found ; and in the large gut also some offensive serous-looking fluid. Case 3. — Chronic Dysentery. Mrs. H., aged fortj^-one, seen with Dr. Theodore Williams, November 10th, 1879. Histori/. — "Had had eight children rapidly ; and was much weakened by long residence in India, where on several occasions she had attacks of dysentery, also cough and expectoration, with well-marked signs of phthisical con- solidation of the left lung, for neaily eight years. Was much troubled hj menorrhagia. For the last month has had i^ersistent dysenterj', the motions being frequent, accompanied by much tenesmus. The motions were scy- balous, and accompanied by much blood. Tongue foul. Patient greatly emaciated. Pulse weak, but normal in frequency. Temperatm-e normal. A well-marked area of tenderness and thickening, about the size of a crown, coidd be made out in left iliac region, over the sigmoid flexm-e. Some tenderness was also observable in the right iliac fossa. Various remedies had been tried — such as ipecacuanha in large doses, starch-and-opium injections, sulphate of copper, and other astringents— but had failed." " To have oil of tm'pentine, ten minims in capsule, three times a day. A week later the tenesmus and blood had quite disappeared, and the motions, though loose, were more natm-al." Case 4. — Chronic Dysentery, ^vr^H Multitle Abscesses •OF Liver, etc. Dr. McConnell. B., a Hindoo male coolie, aged twenty -five, was admitted into Medical College Hospital on November 28th, 1873. He states that almost six months ago he suffered much LECTL'KE III. 153 from " diarrhoea," from which, however, he completely recovered, and has been well until the last eight days, when an attack of dysentery ha,d come on, and he is now passing ten or twelve stools in the twenty-four honrs. Is much emaciated; pulse weak, soft, 132; temperatm-e 99 'S^. There is pain all over the abdomen, and tenderness on pressm-e, especially over the sigmoid flexure. The spleen and liver can both be felt enlarged, and on pressure tender. The stools are from ten to twelve in number in the twenty- four houi's, passed with a good deal of pain and straining. They consist of a little thin feeculent matter, with a good deal of rosy and shreddy mucus. His condition did not improve, in sj)ite of varied treatment, and, two days after admission, bronchitis, with a good deal of congestion of the lower lobes of both lungs setting in, prostrated him still more. He thus died exhausted on October 7th, 1873. Treatment, — Dover's powder with bismuth and soda thi-ee times a day, with a stimulating expectorant mixture every three hours, anodyne enemata, etc. Post-mortem Examination (October 8th, 1873 ; twenty-two hom's after death). — Body emaciated. Rigor mortis only present in the lower extremities. Brain and membranes pale and anaemic ; slightly softened in consistency. Limgs : Hypostatic pneimionia of both bases ; general congestion. Heart : Nothing remarkable ; peritoneum healthy ; no fluid. Liver large ; sm^f ace irregular, presenting a series of circmn- scribed, yellowish-red, slightly projecting nodules, which occupy chiefly the upper sm-face of the right lobe, and a few also in the left lobe. These vary in size from a pea to a pigeon's e^^, and on section are seen to be distinctly circum- scribed abscesses, containing from a few drops to nearly a drachm of thick, greenish-yellow pus ; each is siuTOimded by a dark, well-marked hypersemic zone. The liver-substance is abnormally soft, and exhibits throughout similar circum- scribed suppurating foci ; in addition to which there are numerous circumscribed points of so-called " red softening " (acute inflammation running into suppiu'atiou). No reaction given with iodine. Weight of liver 3 lbs. 13 ozs. Gall- 154 TROPICAL UYSEM'EHY AMI DIARRIKEA. bladder contains about half an ounce of thick, brownish- yellow bile ; ducts free. Spleen large and heavy ; the capsule in parts thickened ; substance moderately firm, dark reddish-brown ; trabecular structure well marked ; weight 1 lb. 2 ozs. Kidneys a little fatty, particularly the cortical structure ; nothing else remarkable. Stomach small ; mucous membrane corrugated, pale ; that of the whole of the small intestine also pale ; no affection of the glandular structures. The mucous membrane of the large intestine fi-om csecum to anus presents an almost continuous series of transversely placed dysenteric ulcers ; the siu'f aces of some are covered by dark, shreddy, and easily- detached sloughs j the majority, however, are quite bare and raw-looking, exposing freely the muscular coat. The sub-mucous tissue is here and there irregularly pus-infiltrated, and throughout thickened. The ulcers become larger and more numerous as the rectum is approached. The sm^rounding unaffected mucous membrane is thick, and for the most part pale or having but a faint rosy blush. Many of the ulcers seem to be of considerable stand- ing, presenting an indolent condition, with pigmented edges. The mesenteric glands are slightly enlarged and soft. Case 5. — Liver-Ahscess and Chronic Dysentery and Diarrhoea. With Mr. Adams. An officer, aged forty-five, a man of temperate habits. Had two attacks of dysentery during the last year in Afghanistan, and was left behind at Safed Sung when his regiment marched to Jellalabad. The second attack was slighter than the first, and occm'red on the march down-country. On both occasions he com- plained of severe pain over the edge of the liver, particularly just below the region of the gall-bladder, and behind under the short ribs. Since the last attack he has constantly been ailing, now from ague, again from diarrhcca, and occasionally from both together. Occasionally pills and aperient di-aughts were LECTURE III. 155 prescribed, but up till Ms arrival in Bangalore in October he was not put under any regular course of treatment. On the day of his arrival at Bangalore he had rather a severe attack of fever, and the diarrhoea increased in severity, the motions being frequent, Hght-coloured, frothy, and accompanied by a good deal of pain both in the bowels and anus. The pain over the edge of the liver also became much more severe ; his appetite also failed, and his nights became restless and dis- turbed. At first ordered him a bitter tonic, but on the 23rd, after consultation, prescribed — ipecac, co. gr. xx., hyd. c. creta gr. xij., sod. bicarb, gr. xx., pulv. iv., one night and morning ; also 1^. Acid. nit. mur. dil. 5iss., tr. aurantii oiv., inf. calumboe §viij., m. ; one tablespoonful two or three times daily. These he continued to take, but mth no apparent benefit ; on the contrary, he is becoming weaker day by day. His motions fi-equent, very loose, light-coloured, and frothy. Taste and appetite gone. Sent to England, The above is an abstract of his case. I saw him on December 18th, 1880, with Mr. Adams. He had arrived at Southampton on the 15th, and came to London on December 18th ; was much fatigued by the journey. He was emaciated and sallow; his skin hot; pulse rapid, 130, feeble ; tongue dry, smooth, glazed ; bulging and fluctuation behind eighth and ninth ribs ; side greatly enlarged ; a large Uver-abscess was pointing and near the surface ; no abdominal pain except over the edge of the liver. Next morning, December 19th, after rest and sleep induced by a morphia draught, the abscess was opened, under strict antiseptic precautions, by Mr. Adams, assisted by Mr. S. Watson, who made a free incision between the ninth and tenth ribs, in a line coiTesponding to posterior fold of axilla. The matter was near the surface, and one pint of thick pus, with clots of thicker pus, was evacuated. The edge of tenth rib was found to be necrosed, and a di'ainage-tube was in- serted. He was relieved by the operation ; his temperature fell ; his breathing, which had been much oppressed, was relieved. On May 3rd the dressings were changed. The discharge 156 TllOPICAL DYSEXTEIIY AXl) DIAHRIKEA. through the drainage-tube was free, but thick ; no putrefac- tion. He slept faii'lj, and took nouiishment well. The bowels acted occasionally ; the excreta were fluid and very offensive. On the 25th he died rather suddenly, after some symptoms of orthopnoea. There had been an increase in the discharge, with some blood. The post-mortem examination took place on December 27th, at 9 a.m. The right lung was condensed by pressure into a dense impervious mass, the lower part adherent to the diaphragm. The left lung was healthy. The heart was healthy, but the right ventricle contained a firm white clot, moulded into the pulmonary ai-tery and extending into both divisions for two inches or so. The right pleura contained a quantity of recent lymph. The diaphragm was adherent to the hver below, the lung and the thoracic wall above. The liver was fatty, but it contained only one abscess, which had contracted to the size of a small orange. The liver was closely adherent to the parietes, and the aperture between the ninth and tenth ribs opened directly into the canity, which was lined Avith flocculent, semi-pui-iform lymph. The spleen was about twice the normal size and rather soft. Kidneys apj)arently healthy. A careful examination was made of the morbid parts by Mr. Alban Doran, of the Royal College of Surgeons, and the follo^ving is his report : — " December 29th, 1880. — I have examined the intestine to-day. 1. The valvuloe conniventes are absolutely normal, excepting in the part of the ilemn where they are nearly effaced ; there, they are deeply congested. 2. The muscidar and mucous and sub-mucous coats of the transverse colon are much thinner than normal ; in the ascending colon there is atrophy of the same coats, but to a less marked degree. 3. The appearance of the mucous membrane is so altered by decomposition, that the slaty colour characteristic of amyloid degeneration cannot be distinguished. 4. Peyer's patches have almost entirely disappeared. In the middle of the ilemn, large shreds of desquamating mucous membrane LECTURE 11 r. 157 hang into the lumen of the intestine. Some of these shreds are discolom^ed, others quite dead- white, precisely like the epi- dermis when desquamating from sunburn or after scarlatina. 5. There are a few superficial ulcers in the sigmoid flexm'e, hut not elsewhere. The mucous membrane of the rectum is abnormally puckered. 6. The muscular coat of the rectum is much thickened. 7. There appears to have been contraction between the descending colon and the sigmoid flexure, but the intestine had been opened when I examined it. 8. Weight of liver and adherent part of thoracic wall, 6 lbs. 1 1 ozs. 9. The liver-substance is pale and very soft and greasy. " Looking at the specimen from the thoracic aspect, with the diapliragm placed in its normal position, and then passing a catheter through the wound in the chest into the abscess- cavity, none of the catheter can be seen, and it appears to run clean into the liver. Hence, as you say, the lower part of the diaphragm, with a reflection of plem-a, must have become fused to the Kver and the chest-wall. About one inch and a half of the tenth rib is necrosed and denuded of periosteum." This is a very instructive case. The pre\^ous history appeared to point to the dysenterj' and diaiThcea as the cause of the abscess ; an example, in short, of multiple pyaemic liver-abscess. It proved, however, to be a single abscess, and the contraction of the cavit}", after the removal of more than a pint of pus, was most remarkable. The effusion of lymph in the pleural cavity and on the surfaces, and generally in the vicinity of the abscess, was verj' remarkable, especially seeing that antiseptic precautions were carefully observed at the time of operation and during subsequent dressing. The fibrinous coagula in the pulmonary artery no doubt accelerated, if they did not cause, death. There was no peritonitis ; and the disease of the bowels was rather that of atrophy and degeneration than of ordinary dj'sentery. The case is interesting and instructive, especially in regard to the liver-abscess and the state of degeneration of the intestines. 158 TROPICAL DYSENTERY AND DTARIUKKA, Case G. — CiiROMf: Diarrtuea., Mrs. M. A. S., aged forty. In July, 1866, she went with her husband to Amoy, South China. Up to 187-3 had toler- able health, interrupted only by siich weaknesses as arose from the great heat, and consequent upon confinements. During that period of seven years she had five children and one miscarriage. At the birth of the last child, in 1873, she caught a severe cold, and lost the use of the right ear, which has never returned. About six months later, bleeding piles appeared, and ha\dng always been of constipated habit, her sufferings were great. Had severe pain after the action of the bowels, and hsemorrhage. In March, 1875, she came to England, and in December of that year had an operation for internal piles. Having recovered by the autumn of 1876, returned to China. In January, 1877, haemorrhage again returned, but without pain, and continued on and off for some months. Her medical adviser ordered her to take plenty of exercise, and to eat fruit very frequently. Was better, and got on till August, 1878, when the monthly illness (after being more than usually profuse) stopped, and her health at once declined. The abdomen became swollen, appetite failed, throat was relaxed, and covered with small ulcers, and she was much exhausted. Milk and port wine were ordered, and she was advised to give up teaching the Chinese. In December she became a little stronger ; the catamenia returned for one day, and since that have quite ceased. In February, 1879, the sjanptomsof weakness all came on again, attended by frequent sick headache and bilious vomiting, till at length she could retain no food, and was so prostrate as to be obliged to keep her bed for some weeks. It was at this time the tongue showed the first appearance of soreness, and she lost flesh considerably. All through the spring and summer she had regular attacks of sore tongue and vomiting. The rule was, to be one week ill and the next better and able to eat. This went on till the middle of July, when the state of the tongue "v^as verj' bad ; her mouth inside and lips LF.CTURE 111. 159 became much swollen. For the burning, shooting pains she got relief by sucking ice for several houi'S. As soon as the inflammation subsided, she was sent away to Chefoo, North China, to avoid the intense heat, which greatly aggravated the disease. She had not been twelve hours at sea when diarrhoea set in violently. In a week she anived at her des- tination greatly prostrated, went to bed, and the next day had (as it was thought) an attack of English cholera. The worst sjTuptoms soon yielded to remedies, but the diarrhoea con- tinued unabated for a period of seven weeks, attended by bleeding from piles. The action of the bowels in appear- ance was like small seeds and water, and very foetid. The diet was milk, beef -tea, chicken soup. Had Dover's powders, opium, bismuth, and charcoal, till a doctor at Chefoo pre- scribed acid. This changed the natiu'e of the diarrhoea to a more healthy form, but left her more prostrate than before. During all these weeks her tongue was quite free from sore- ness. Being very desirous to take a little meat and ale, it was allowed, and the diarrhoea gradually passed away. As the weather was now getting cold, and she was a little stronger, she was advised to retm-n to Amoy. On reacliing Shanghai, it was quite hot, her tongue became sore, and very foetid diarrhoea again set in. In this state she went on board, feeling as though she would die of himger, and yet quite unable to take food, or even liquids, as everj^hing retiu'ned. Before arriving at Amoy the vomiting and diaiThoea had partially subsided. Landed on October 4th, and the disease again took the regular form of better and wc^'se till the wdnter set in ; then the attacks of sore tongue and sickness (though coming with the greatest regularity as to time) became less in severity, but, as the diarrhoea was not checked by the colder weather, she was ordered to go to England, and left on March 4th last. As she got into the hot climate the disease rapidly increased, diarrhoea took the dysenteric form, and bleeding jiiles appeared. Coming through the Eed Sea the weather was very trying — a diy, hot wind blowing— and she had very severe attacks of cramps all over the hody, which lasted an hour at a time, accompanied by faintness and coldness. 160 TKOPICAL DYSENTKRY AND DIARRHCEA. Relief ^vas obtained by bottles of hot water being placed all about her. As she got into cooler weather she became rather better, and the last three days at sea was able to take a little solid food. The day after arrival (April 30th) excessive diarrha^a, with sore tongue, again returned — con- tinued — and she grew worse than ever. A bad cough, shortness of breath, and great prostration came on, with loss of flesh to such an extent that she became nearly a skeleton. It was in this state (just three weeks after landing), on May 22nd, she began to take milk only as diet, and the bael fruit as medicine. In fre days the bad symptoms all sub- sided. Cough, short breath, flatulence, nausea, vomiting, heartburn, and diarrhoea passed away, and her stomach felt calm, cool, and comfortable. The greatest discomfort was that of real hunger, which, however, diminished when she got to three pints of milk daily. The bowels acted mostly twice a day, in very large quantities of pale formed sub- stance. The tongue continued sore with only one short interval till June 15th, when it began to heal, and b}^ the 23rd it was quite free from soreness, and began to increase in size and healthy appearance from that time. She had also been gaining flesh and strength ever since. About the middle of July began to take three quarts of milk, and con- tinued on this quantity till September, when she was allowed a little beef -tea and macaroni once a day in addition. Had no other change till October 26th. For a period of five months she lived on milk alone, and derived the greatest benefit, com- bined with retaining the recumbent position for nearly the whole of that time. She writes that the change in food has done her no harm, and that she is in a fair way of fully regaining her health and strength. I may add that I saw this patient, of whose history tlie above is an abstract of her own statement, some time after this account was written. She had greatly improved in liealth, and was contemplating a return to China. LKCTTTKE Til. KJl Case 7. — Chronic Diarrikea. J. B., aged thirty-four, a tall man, much emaciated ; com- plexion salloAV ; tongue red and smooth ; weak, but not feeling otherwise ill ; thirst and appetite rather above the average. Has been in India for some years, and has been suffering from chronic white diarrhoea. The following is a brief statement of his case by himself : — " First went to India end of 1863, and resided in Assam ; came home early in 1871; returned in 1872; came home again in 1876, and returned end of the year. Dimng the whole of this time liad kept good health, but usually had slight attacks of fever and ague during rains and beginning of cold weather. Usual weight eleven stones, or a trifle under. End of May, 1879, had a bilious attack and fever and ague. Did not get quite right again, and in June had a return, followed by diarrhoea. At the end of the month left by steamer for Calcutta and then to Ceylon; stayed a fortnight. Diarrhoea increased, but otherwise felt pretty well. Arrived home at end of August ; had medical advice, but diarrhoea still increased, always coming on at night. At last increased to three or four motions daily, and two or three at night. Ravenous appetite the whole time. With the exception of weakness, did not otherwise feel very ill. Came under treatment early in December, 1879. Lived on milk only for six weeks, taking also bael mixture. After two or three weeks diarrhoea decreased, particularly at night, soon after entirely ceasing at night. I then took to arroA^TOot and puddings, afterwards eggs and fish. B}^ the S2')ring I was in pretty fair health. At this time I was taking steel and also bael conserve. Felt very well by summer, and my weight increased to twelve stones. When at the loA\-est I scaled nine stones two pounds ; I am now twelve stones foiu" pounds. My tongue became very sore soon after leaving Calcutta ; I did not care to smoke, neither could I take anything highly seasoned. Tongue became worse afterwards, bright -red in appearance, and a glazed look. Soon after taking milk only 162 TROPICAL DYSKXTKUY AND DIAIUIIKEA. my tongue improved, so I could enjoy smoking, and, with slight relapses, it has gradually returned to its original state." In March, 1880, he was perfectly well, tongue normal, and for some time had been taking his ordinary food. Case 8. — Tropicat, Diarrhcea. With Dr. Hooper. " F. P., aged foiiy-eight, formerly a stockbroker. He had arrived in England the day before from Biu'mah. Found him much wasted, extremely feeble ; skin thy and shrivelled ; legs cedematous from groins to toes ; hair thin, diy, scanty ; teeth loose and decaying, and gums soft and spongy ; tongue smooth, red, glazed, like half-di'ied steak ; mouth sore, with a few aphthous patches ; spots, cracks, and scales of a reddish- brown colour upon calves of legs and shins ; face freckled and tanned by the sun, but generally anoemic. Great craving for food ; flatulent rumblings in bowels. Stools six or eight or more daily, pultaceous, white, and honibly offensive No bile in skin, conjunctivae, or urine. Liver apparently shi'unken, its area of dulness hardl}' reaching margin of ribs. Ai'ea of splenic dulness also very limited. Xo evidence of heart or lung disease. Urine clear, pale, containing neither bile nor albumen. Pulse 80, soft ; temperatm'e 98°. No history of intemperance or of s^-jihilis. 8ays he had ' low fever ' in Biu'mah ouce for a few days." Treafiiiciit. — June 9tli. — Grave him some suecus taraxaci, gentian, and nitro-hydi'oehloric acid ter die, and five grains of Dover's powder om. n. Diet, arro"\\Toot and milk, rice and eggs. Brand's essence of beef, some good grapes, and a little claret. 14th. — Finding more diarrhoea, I ordered a diet of milk (ehieliy) and farinaceous food, and gave two grains and a half of quinine ter die. 21st. — No better. Stools very numerous, thinner and yellower than tliey were ; to-day like 3'olk of i^^g and milk LKCTURK III. lO'i whipped together, with surface frothy, sediment chalk-like, horribly foetid. Q]]dema limited to dorsum of each foot ; tongue clean, red, smooth, dry; seems to be losing power. 24th. — Saw him in consultation. Milk only was ordered ; a little spirit niiglit be given, if the condition of patient should urgently demand it, but not otherwise. All the organs were shrivelled and wasted — liver, spleen, intestines, etc. Tiratmcnf. — 1. A wineglassful of milk every hour. 2. Rub gums with a soft brush and eau de Cologne. 3. Wash mouth with a wash of ,~j. of borax, 3j. chlor. potash, 3ij. tinet. mj'rrh, and §viij. water. 4. To take at 7 a.m. and 4 p.m. half an ounce of the following mixtiu'e : — Mist, belt© §vij., tr. eucalypt. rubr. §j., m. 28th. — No stool for last sixty-two houi's. Pulse 80 ; temperature 98° ; but gets thinner and weaker {I.e., we all think so). July 5th. — Stools much less frequent than on June 2 1st, and much less fluid — now just like putty. Does not appear to gain flesh or strength ; seems thinner if pomhle. Craves for something substantial. 8th. — Being so thin and weak some corn-flour was added to the milk ; but the stools at once became more fluid and more frequent, so we retm-ned to milk pure and simple; and altliough many times after this a similar alteration was tried, the residt was always the same. Soon after this the case went out of my hands. Mr. P. left Camberwell, and I heard nothing of him till about the middle of October, when, to my astonishment, his mother wrote to say that he had just n-alkcd info her //ousr, and although thin, he was full of life, hojie, and spirits. The above is an abstract of Dr. Hooper's account of this case. I saw him in October, 1880 ; he was quite well. On February 4th, I hear that he is not in so satisfactory a condition, but that lie is eating and diinking like other people, and able to walk five or six miles daily. >i 2 164 tkoricai, dyskntery axj) j)iakrii(ea. Case 9. — Tropical Diarrikka, with Albuminuria. Abstract of Case by Dr. Daniel, Epsom. " Captain T. left England for Burmali in June, 1864, and ai-rived there in October. When in Bunnah he was quartered at Tonghoo, and while there (in 1866) had insolation, and for more than a month afterwards was unable to retain anything in his stomach, and ever since that time, until a few weeks ago, the three outer fingers of both hands were benumbed, which numbness was felt as far up as the elbow. Since that time he has been subject to attacks of cramp, in both legs and hands, the acuteness of which has varied ; but diu'ing the last few months these have ceased. " He left Burmah for Madras in February, 1868, and was quartered at Bangalore until invalided from there in August, 1869, for disease of the liver, and he so far recovered as to be able to return to India in February, 1871. He was then quartered in Calcutta, and there had a slight attack of cholera. At his next station, Allahabad, he had a few slight attacks of simple fever. He returned to England in November, 1872, and again left for India in February, 1875, and joined his regiment in Raneket, N.W.P. He again left Raneket for Englaml in November, 1876, and during the latter part of the stay in that place he suffered at times a biuniing sensa- tion when making water, and experienced considerable pains across the loins, which were increased by riding. These pains increased on the voyage home, and became still worse in England. On his retm-n to England in 1877, he was quartered at Portsdo-wai Forts, Parkhurst, and Aldershot, and finally retired from the service on May 1st, 1880. " I first saw Captain T. after his retm-n from India in 1873, and found him suffering from enlargement of the liver to the extent of nearly tlu'ee inches below the ribs, and ascites filling about two thirds of tlie abdominal cavity. This was accom- panied by dyspnoea, iiTCgular and intermittent action of the heart, and frequent attacks of cramp-like pain in the chest, LKCTUKK 111. 165 wliicli was generally relieved by diarrhoea and vomiting. There was also occasionally albnmen in the mine. In the course of a few months most of these symptoms disappeared, though occasional vomiting and diarrhoea continued. He left for India in 1875, and at the end of two years returned to England, when I again saw him. At that time the liver was not much enlarged, but the action of the heart was ii'regular and the albumen more persistent. In the spring of 1880 I again saw him. He had shortly before been thrown from his dog-cart, which seemed to have shaken him considerabl}^ He looked sallow and emaciated ; the heart's action was at times feeble and then again tumultuous ; the lu-ine contained casts, mostly of a hyaline character, as well as albumen. The liver was only slightly enlarged, and there was no dropsy. Was prescribed iron and iodide of potash. In the summer he went for change of air to the West of England — Torquay, Fal- mouth, etc. — but his strength seems to have steadily decreased, and he returned home in October. He was then excessively emaciated, sallow, hardly able to walk without falling, with weak cardiac action, and almost constant sickness and diarrhoea. On November 19th, 1880, the fresh bael fruit and a diet consisting solely of new milk were ordered. After the adoption of the milk diet, the sickness and cramp-like pains ceased, and a few doses of the bael only were required to check the diarrhoea. At first two or three pints of milk were taken, but at the present time (January) he takes nearly four quarts daily and nothing else, either nourishment or stimulant. His improvement has been constantly progressive, with the exception of one slight bilious attack, and he appears to be recovering his health rapidly ; his strength and weight have increased, his bowels act regularly, his sleep is undistiu-bed, and he has in a great measiu'c lost his former sallow, cachectic look. His mine, which shortly before December 9th contained some casts and a trace of albumen, is now quite free from either." On January 2oth, 1881, Dr. Daniel ^\T.ites that he is rapidly recovering. His weight has increased from nine stones eleven pounds to eleven stones five pounds in a IGG TRoricAi, j)Vsi;N'n;RV am) I)1\i\ ozs. Kidneys both in a far advanced stage of cystic degeneration, and the pelves and calyces are much dilated, and show a corresponding atrophy of the secreting structiu-e. Stomach small, mucous membrane thin, of a brown or greyish-brown coloiu- ; the mucous membrane of the duodenum and jejunum presents nothing remarkable, but throughout the ileum there are found at short, irregular intervals, small, superficial, weak-looking 170 T]U)1'ICAL 1)YS1-,XTK1{Y AM) DIAKHIKKA. ulcers with pigmented Leases. The whole of the small intestine is much thinned, its coats semi-transparent ; but this is most marked in the ileum. The mucous membrane of the large intestine presents a dark slate-colour from extensive pigmenta- tion of the siu'faee, but there are no glandular lesions, ulcera- tions, etc. The stomach contains about ten ounces of greenish bilious fluid ; the small intestine about three ounces of similar fluid, but thinner ; the large gut half an ounce of muddy- coloured fsecal matter. The mesentery is loaded with thick yellow fat. The glands are slightly hj'perajmic, not en- gorged. Case 12. — Morbid Preparatiox. Case of a native male adult, who died in the Medical College Hospital, Calcutta, fi'om chi^onic dysentery. The whole of the mucous membrane presents a thickened, cor- rugated, honeycombed appearance, is covered with innumer- able small, irregidar-outlined idcers, the majority of which, in the lower part of the bowel, reach the muscular coat, which in turn is softened and shreddy ; a few have penetrated still more deeply, and have almost perforated the gut. No details of the liistory of this case are supplied, but it is a good example of the sort of pathological lesions that may be found in cases of chronic dysentery. Case 13. — Morbid Prepara.ti()X'. A case of chronic dysentery in a native male Hindoo, who died in the Medical College Hospital on December 4th, 1875. A portion of the transverse and descending colon, with the sigmoid flexm-e and rectum preserved, showing extensive chronic indolent dysenteric ulceration of the mucous membrane, with very dark pigmentation of tlie ulcers and surrounding tissue, and thickening of tlie muscular coat. This also is an excellent illustration of the pathological condition and morbid anatomy of the bowel in chronic dysentery. LKCTURE III. 171 111 coiicludiiig-, I must exjiress the great obligation that I am under to Professor Aitken, F.R.S., of Netley, for the valuable preparations he has allowed me to place before you from the Netley Museum, as well as for much valuable information derived from his -svaitings. I am especially indebted to Dr. McConnell, of Calcutta, for the interesting recent specimens and cases with which I have been able to make these lectures, I hojie, of some prac- tical value ; to Drs. K. McLeod, Oayley, and Chundra, of the Medical College, for their valuable clinical contributions ; and to Dr. Jones, of the Calcutta General Hospital, Dr. Coull Mackenzie, and Moulvie Khan Bahadoor Tameez Khan for most valuable reports ; to Mr. Buckland, of the Civil Service, for valuable information regarding the shij)ping population of Calcutta ; to my old friend and colleague, Dr. Chevers, for his valuable communication on the exuviae of dysentery ; to Sm'geon-Major Dr. A. Clarke, A.M.D., and Fleet-Surgeon Dr. Lilburn, R.N., for valuable statistical in- formation ; to Mr. Alban Doran, of the Hunterian Museum, for the care with which he examined and reported on certain morbid specimens ; and, lastly, to the sanitary officers, who are doing such important work in India, and to the many authors, ancient and modern, from whom I have derived information. It only remains for me to thank you, sir, and the members of the Society, for the indulgent patience with which you and they have listened to me. ON THE BAEL FRUIT, AND ITS MEDICINAL PROPEETIES AND USES.* Ha^'ing recently received from Calcutta some specimens of the Indian bael fruit, which arrived in perfect order, I take the opportunity of directing attention to a remedy of considerable repute in India in the treatment of some forms of bowel complaint, and which I think might be of use in those forms of chronic diarrhoea and dysentery that are seen in persons who retmii to Europe after residence in India or other tropical climates. The bael is already well kno-svn, and is included in the list of drugs in the British Pharmacopoeia, where it appears in the form of the dried fruit and the liquid extract, which is " prepared from the half -ripe fruit brought from Malabar and Coromandel " — known in fragments of a brownish-orange-coloured dried pulp aclliering to the rind of the fruit. It has been, says Mr. Squire in his valuable commentary on the Pharmacopoeia, " extolled in the treat- ment of diarrhoea and dysentery, and is given alone or in combination with other astringents, such as the red gimi of the Eucalyptus rostrata." This liquid extract of bael is prepared by macerating the di"ied fruit in water and rectified spirit. The fluid is to be evaporated, pressed, and filtered ; an intensely brown fluid is the result, of which ";]. to 3ij. may be given as a dose. This and the diied fruit are the only officinal forms in which it is known, so far as I am aware, in * From a Lecture delivered to the Studeuls of the Charing Cross Hospital in 1877. ON THE HAEL FRUIT. 173 this coimtiy ; and though I do not wish to disparage them — for I really know little of their properties in this state — yet I imagine they have neither deserved nor acquired much repute as medicines. I think the case is different in regard to the fresh fruit and its preparations, and to them I wish to call attention, for it is quite possible, in these days of rapid communication, to procure supplies direct from India ; it is well that you should be ac- quainted Avith a remedy that often proves valuable there. Do not suppose that I wish you to think of the bael fruit as an unfailing or specific remedy ; it is nothing of the kind, but simply one that is occasionally very usefid in some forms of chronic disease, where other remedies fail. It has the advantage, moreover, of being simple, and easily procured. I am an advocate for utilizing the local remedies of the countries in which one may live, and would recom- mend you to make yourselves acquainted ^vith them as much as possible, not merely as a matter of economy, but because it renders you more independent of costly Eiu-opean drugs, and because it is right to develope and encourage the use of such as are really reliable and effective ; and there are many native remedies that might with advantage be introduced into European practice. The example to which I now invite attention is the fruit of an am-antiaceous tree, known to botanists as the ^gle marmelos. It is comnion nearly all over India, and every- where is held in much esteem, and indeed veneration, by the Hindoos, who regard it as a sacred tree, its ternate leaf being considered as a ty])e of the Hindoo trinity, or of Siva, a member of the sacred triad. It is, moreover, thought to be pervaded by the presence of Durga, or Kali, the vnie of Siva, and hence has a double odour of sanctity, and is much grown around pagodas and temples. It is valued not only on this account, but because its fruit, leaves, bark, and wood are all thought to be endowed either vdth medicinal properties, or to be of value in other ways. I proj^ose to consider only the medicinal properties and uses of the fruit. Descriptions of the tree may be found in most works 174 ON THE UAEL FKUIT, on the botany of India. Dr. Clegliorn — a high authority on all that regards Indian forest and plant life — has given an account of it in the Inditni Annah of Medical Science, and he tells us that it has many synonj'ms, of which the following are some : — ^gle Marmelos (Wight and Arnott), Feronea Pellucida (Itoth), Cratoeva Marmelos (Linn), Belva Bilva, Maridu {Sir W. Jones, in "Asiatic Researches"), Cov-alum (liheade Hort. Malabar), Bael, Bil, or Bela (Hindi Bengali), Beli (Cingalese), Naraidu (Telinga), Tanghala (Malay), Willamaram (Tamul), Bengal Quince, Stone Apple (English). In Bengal and Noi-thern India it is commonly called Bael or Bel. The tree is moderately large — twenty, thirty, to forty feet high ; the branches are irregidar and not numerous. The leaves are ternate, and dotted like those of other orange trees ; flowers are whitish and sweet-scented. It has sharp strong axillary thorns, which are more numerous in the wild, imcared-for, stunted trees growing on poor ground than in the cultivated trees, on which also the fruit are much larger and more highly flavom'ed than on the former. The fruit is a large globose or obovate hespe- ridium or orange, of var}dng size, from a small orange to that of the indiA'idual before you, with a hard woody rind, with a fragrant aromatic epidermis. The interior is a yellowish aromatic and astringent pulp, with a pleasant and peculiar flavour. It contains ten to sixteen cells, each lodging a tomentose seed, imbedded in a tenacious viscid transparent mucus, which has a peculiar, somewhat terebin- thinate flavoiu*. The rind is pungent and aromatic, with essential oil. As I have already remarked, the tree is sacred to Siva, and the worship of this god, under the name of Mahadeo, is prevalent everywhere throughout India. " The daily ceremonials are of a severely austere and simple character," says Monier Williams ; " water from a sacred river is poiu'ed o\'er his symbol, with perhaps a few oblations of flowers, but often there is nothing presented ])y the wor- shippers but the Bilva, or bael leaf." AXD ITS MKDIflXAL PROPERTIES AND USES. 17/ The foUomiig description of the tree is by Dr. Brandis, F.E..S., the Director- General of Forests in India : — ^^ ^gle Corrca. — Leaves alternate, trifoliolate ; leaflets pellucid, punctate. Flowers hisexual. Calyx small 4, 5, dentate, deciduous. Petals 4, 5, imbiTcate. Stamens nume- rous, with shoi-t subidate filaments, and long linear anthers. Ovary on cylindrical disc, with a fleshy axis, and 10 to 20 small cells near the circumference, with numerous ovules in each cell attached to the central angle. Stigma capitate, obtuse, deciduous. Fruit globose, with hard, woody rind, 8 to 16 celled, filled with an aromatic pulp. Seeds numerous, oblong, flat ; testa woolly, covered with a viscid fluid, I. ^. Marmelos, CoiTea ; Eoxb. Cor. PI. t. 143 ; Fl. Ind. ii. 579 ; "Wight and A. Prodr. 96 ; Wight Ic. 16 ; Bedd. Fl. Sylv. t. 101. The Baeltree — Sanscrit Bilm, Mahura. Yemac, BeJ, bi/, hila, bill. Local name Mahaka-Diorra, Gronds., C. P. ; U.s/iifbeii, Bmin. Grlabrous, armed with axillary, straight, strong, sharp spines one inch long or more. Leaflets three, rarely five, ovate-lanceolate, crenate, terminal long-petiolu- late, lateral nearly sessile. Flowers greenish- white, with a fine honey scent, or short lateral panicles ; pedicles and calyx pubescent. Calj-x flat, teeth indistinct. Petals oblong, cori- aceous, thickly dotted. Filaments occasionally fascicled. Fruit globose, oblong, or pyriform, two to five inches diameter, with a smooth grey or yellow^ rind, and a thick orange-coloured, sweet- aromatic pidp. Wild in Siwalik tract and outer Himalaya, ascending to 4,000 feet, from the Jhekmi to Assam ; also in Oudh, Behar, Bengal, Central and Southern India, and Bminah. Often gregarious when wild. Cidtivated throughout India, except in the northern part of the Punjaub ; frequently planted near Hindoo temples. Leaves shed about March and April ; the new foliage appears in April and May. Flowers about May ; and fi-uit ripens in October, November ; remains long on the tree, "WTien cultivated, a middle-sized tree to tliii-ty-five feet high, with a shoi-t, erect, often fluted, irregidarly- com- pressed, and scooped-out trunk, attaining a girth of seven feet ; branches few, extremities often drooping, forming a 176 ON THE RAEL FRllT, narrow oval lioad. Wild (in North- West India) generally a small scrubby tree. Bark of trnnk and larger branches half an inch thick and more, outside soft, corky, light cinereous or bluish-gre}^, with large dark stains, and irregular, longitudinal, shallow furrows. Wood light-coloured, mottled with darker wavy lines and small light-coloured dots ; medullar}" rays indistinct ; even, close-grained, forty to fifty pounds per cubic foot. The tree, being valued for its fruit, is not often felled ; but the timber is esteemed for strength and toughness. Used in construction for pestles of oil and sugar-mills, naves and other parts of cart's, and for agricul- tural implements. Twigs and leaves are lopped for cattle-fodder. The tenacious pulp of the fruit is used medicinall}^ in diarrhoea and dysentery, as sherbet, and as a conserve. Dry, it keeps well as a hard, transparent substance. It is also considered as an excellent addition to mortar, especially in building walls. Snuff-boxes are made of the shell of the fruit ; the leaves, root, and bark are used in native medicine ; from the flowers a scented water is distilled. In 1868 a Pharmacopoeia for India was publislied, under the auspices of Grovernment, edited by Dr. Jolui Waring, a distinguished member of the Madi-as Medical Service. This valuable work is based on the British Pharmacopoeia, and, while affording all the information contained in that work of practical use in India, embodies and combines with it such supplement arj' matter of special value in tliat country as sliould adapt it to meet the requirements of the Indian Medical Department. In this work the following descrip- tion is given of the forms in wliich bael is prepared for use : — • 1. Bael mixtm-e (sherbet): "Two ounces of the pulp, two ounces of A^diite sugar, four ounces of water ; mix them thoroughly and add ice ; it may be strained through linen, and is an agreeable form in which to take it, and is so taken by many in India when the bowels are deranged; for its beneficial action in giving tone to the intestinal tract. It is generally taken earl}^ in the morning, and may be repeated AND ITS MEDICINAL FROPERTIES AND USES. 177 twice or thrice daily to the extent of a large wineglass or small tumbler full." Waring says : — " It possesses all the aroma of the fruit, and when prepared with ripe fruit is not only astringent when diarrhoea exists, but possesses the singular property of being aperient if the bowels be irregular or costive. When the patient is much reduced in strength, and the stomach is irritable, the above mixture sometimes disagrees. It might then be given in smaller and repeated doses, and if these are rejected the extract )i)aij be tried." The Liqmd Extract (Ext. Bel?e Liquid.) : — " Take bael fruit 1 lb., water 12 pints, rectified spirit 2 fluid ounces; macerate the bael for twelve hours in one-third of the water, pour off the clear liquor ; repeat the maceration a second and third time for one hour in the remaining two-thirds of the water ; press and filter the mixed liquors through flannel, evaporate to foiu-teen fluid ounces, and when cold add the rectified spirit ; " dose from one to two drachms. This extract, prepared from the diied bael imported into England, appears to possess much less medicinal power than the extract and mixture prepared from the fresh fruit in India. This, indeed, is the preparation of the British Pharma- copoeia, about which I have already expressed doubts as to its activity. The Extract of Bael (Extract. Belae), made from fruits that are ripe and have thin shells or rinds : — " Extract the pulp, place it in a vessel, add water sufficient to cover it, stir for two hours, and strain through stout calico. Eepeat the process until the fluid which passes is tasteless ; evaporate over a water-bath to the consistence of a soft extract," This preparation retains all the aroma of the fruit. Dose from half a cbachm to one drachm twice or thrice daily. It is said to keep better if made from the unripe fruit. There are other forms in which it is administered ; I will mention the most important of them. Mr. A. Grant, of the Bengal Medical Service, describes several, in a paper in the ItxUaii Annals, vol. ii. of 1855, in use in Bengal ; for example : — 178 ON THE 15AKI, I'liriT, " Tlie imripo fruit, squeezed and kept exposed to the air for a whole night, is then boiled and strained and sugar added. Of this a wineglassful is taken twice a day." He says the bael is known to be carminative in the form of preserve or syrup. The sj^'up is prepared thus : — Pulp of bael and sugar, each 2 tolas = ~;xj. ; Issofgool (Plantago Isphagoola) bran, 6 mashas = ojss. ; rose water or confection of roses, 1 tola = 7)VJ . ; water a wineglassful ; mix ; give three or four times a day. In dysentery the following formula is used : — Bael mixed with dried shell of Grarcinia mangostana, ~,j ; flour of pomegranate, 3j. ; sjTup of bael, 3vj. ; mix for a dose three times a day. As to the use of the bael sherbet I have already described, Mr. Grant makes the following remarks, in which I quite conciu-: — "It is not only astringent, but possesses the property of being aperient if the bowels are irregular or costive ; this last quality it seems to derive from being stomachic and promoting assimilation. "When the patient is much reduced in strength, and his stomach weak, the sherbet sometimes disagrees; it ought then to be given in smaller doses." Bael marmalade, according to Mr. Grrant, is prepared in the same way as orange marmalade. It is eaten on bread, and is said to keep well. Dr. J. Jackson gives the following recipe for bael con- serve : — " Take forty bael fruit, pass the pulp through fine muslin (no water to be added), take 12 lbs. of fine white sugar, boil it into sja'up, then add the bael, and boil them together over a slow fire until the whole is made into a jelly." " But," says Mr. Clrant, " as at times, however, all the above preparations will, eitlier from tlieir bulk or sweetness, disagree with the patient, it becomes an object to obtain the medicine in a more concentrated form, more convenient for prescribing." Accordingly, Mr. Scott, of the Grovernment Dispensary in Calcutta, devised the following formula for an extract, which Mr. Grant savs he tried with favourable AND ITS IMEDICINAL PROPERTIES AND TTSES. 170 results. This extract will keep for any time ; it retains the aroma and taste of the fruit and its medicinal principles, the starch and other insoluble portions of the fruit only being rejected. Its consistence is uniform, like molasses ; its colour dark brown ; its smell that of bael. The dose is from 3ss. to 3j. two or three times in the day, or even oftener. It should be used recent, and he thinks it does not keep so well as stated by Mr. Scott. The extract prepared from the unripe keeps better than that from the ripe fruit. This is the formula : — Take the pulp of the ripe fruit with their shells, put it into a vessel and cover it with water; then clim-n it as you would chiu-n butter for a couple of hours. Throw this on a calico strainer, and when the whole of the clear solution has passed through, replace the contents of the strainer in the vessel with half the quantity of water, and churn again for a couple of hoiu's ; filter as before, and con- tinue to do so until the liquid passes through the filter tasteless. While the process is going on, bruise the shells of six baels and boil them well in two pounds of water, filter the solution through the calico strainer, add to it the filtered solution of the fruit, and having put the mixed solu- tion in an evaporating dish over a water-bath, evaporate them down to the consistence of a good extract. If the medicinal properties of the bael depend on the tannin it contains, this extract, which is made only from the soluble portion of the fruit, must contain it also in all its integrity. Mr. Scott gave also a formula for concentrated syrup as follows : — One ounce of the extract dissolved in twenty ounces of water, adding eight or ton ounces of sugar-candy ; then evaporate it in a water-bath to the consistence of a syrup. The late Dr. Chuckerbutty, Professor of Materia Medica in the Medical College of Calcutta, recommended a preparation of dried bael to be used when the fresh fruit is not procurable, which is the case for some time each year. The pulp is strained through a coarse sieve, and is then kneaded into cakes and baked, to be eaten like a biscuit. This contains all the astringent properties of the fruit, it is said. This process of preparing the dried bael was devised N 2 180 ON THE liAEl, FRl'lT, by Mr. Bowser, the energetic and iutelligent Steward of the Calcutta Medical College Hospital. Other preparations are sometimes made with the bael after it has been partially roasted ; and the Hakeems and Kobirajes, I believe, prefer to use it in this form. Dr. Chuckerbutty occasionally recommended the use of the biu-ned bael in the treatment of bowel complaints. Dr. O'Shaughnessy, in the " Bengal Dispensatory," says : — " The statements we find in works on Oriental materia mediea are very various as to the qualities of this tree and its products. Rheade says a decoction of the bark of the root is considered in Malabar to be very useful in hypo- chondriasis, melancholia, and palpitation of the heart ; and that the leaves are used in decoctions in asthmatic complaints. The same authority sa}"s that the unripe fruit is of use in diarrhcca. " Among the Javanese the fruit is deemed very astringent. Roxburgh correctly states it to be delicious to the taste, and very fragrant." In the " Asiatic Researches," vol. ii., page 349, it is stated that " the fruit is nutritious, warm, and cathartic — a cnrious combination of qualities — its taste delicious, its fragrance exquisite. Its aperient and detersive qualities, and its efficacy in removing habitual costiveness, have been proved by constant experiments. The mucus of the seeds is for some pm-poses a very good cement." It is, indeed, remark- able how hard the mucus becomes when dry. In the " Transactions of the Medical and Physical Society of Bengal," vol. iv., p. 110, Baboo Ram Comul-sen gives an account of the uses of the fruit and various parts of the plant. His botanical description is that given by Dr. Carey, and the following is an extract from the work refeiTed to, giving it in detail : — " In Bengal the parts of the tree which are employed are the bark, the root and stem, tlie leaves, and the fruit, both immatui'e and ripe. Tlie bark of the tree is peeled wliilst fresh, and a decoction of it is made, in the proportion of two tolas, or about an ounce, to eiglit cliittacks, or about a pint, AND ITS MEDICINAL PIlOrEllTIPlS AND USES, 181 of water. It is boiled to one-foiirtli, and administered in bilious fevers. " The bark of the tree is sometimes used in fever, but rarely alone, being more usually one of those mixtures which are known as combinations of fourteen or eighteen substances, and given in remittents. When used alone, it is given in a similar decoction as the bark of the root. " The expressed juice of the leaves, diluted sometimes with a little water, is commonly given in colds and incipient fevers, when the patient complains of general dulness, pains in his limbs, and sense of fulness of the stomach. The juice is slightly bitter and pungent, and induces per- spiration. " The young leaves are also used in ophthalmia, and are made warm, and so applied to the eyes, to relieve pain and inflammation. The imripe fruit is cut into small slices and dried, and a decoction is formed of the dry pieces by boiling them in the same proportion as the bark. It is in this preparation that the medicinal properties of the plant are most decidedly manifested, and the decoction of the dried imripe fruit is a most valuable remedy in diarrhoea and dysentery. It is particidarly serviceable in the bowel com- plaints of children, but is also of benefit in several stages of such diseases in adults. The other forms in which the fruit is employed belong rather to diet than medicine, but they deserve to be noticed as employed in such disorders. A preserve is likewise prepared from the fruit before it is ripe, by boiling with syrup, which is also given to patients labouring under bowel complaints, with benefit, when every other article of food is the cause of fresh excitement, and attended with a feeling of oppression after being taken into the stomach. The ripe fruit is also beneficial in the same way ; a sort of sherbet is prepared from it with tamarind- juice, which has rather an opposite effect, but it is on that account beneficial in fevers and inflammatory affections attended with thirst. The glutinous matter about the seeds is used by planters as a size and varnish. The bael is not the less esteemed by the Hindoo that the tree is held particularly 182 ON TUK liAK], FKLIT, sacred to Maliadoo, and is always \vors]ni)ped at festivals celebrated in honoiu' of him or his spouse, at the Diu'ga Pooja holidays and similar celebrations." The medicinal virtues of this plant are probably due to the astringent, aromatic, and demulcent properties of the pulp. It contains a considerable quantity of tannin, essen- tial oil, balsam, and aromatic principle in the pulp, in the rind, and in the tenacious mucus siu-rounding the seeds. These may be preserved to a certain extent in the dried preparation, but the fresh fruit is in all respects better and more active, and as it can be so readily imported, there is no reason that I know of why it should not be brought into use. There can be no doubt that the bael is a very ancient remedy among the native physicians of India, albeit Dr. "Wise does not refer to it in his " System of Hindoo Medicine." It is referred to in the Ayur Veda, the book of Sushi'uta, a Hindoo System of Medicine, dictated to him by the " holy sage and physician Dhanantwari " — a work still of great authority among Hindoos. It continues to be a favom-ite remedy among medical men of all denominations in India in the treatment of chi'onic bowel complaints, and it is not unfrequently given in combination with astringents, such as the kutch or catechu. The siiecimens before you, which have been in England since March, and are perfectly fi*esli at the end of May, are remarkably fine ones, and rather larger than those commonly met ^\ith — they have been evidently selected — in the Indian bazaars. You will recog- nize the peculiar fragrant aromatic odom', the yellow colour of the pulp, and the viscid mucus surrounding the seeds, which. Dr. Brandis tells us, is used for various industrial as well as medicinal purj)oses ; a great contrast with the dry form in which the fruit is generally imported, and as you see it here. Mr. Squii'e has kindly undertaken to reinvestigate the question in its pharmaceutical aspects, and I trust he will succeed in adding some useful preparations of this fruit to our list of remedial agents, and that both in the fresh and j)rescrved conditions it will be brought into use in England. The bael is not, as j'ou will have gathered from what I AXl) ITS MEDI('I>^\L PROPEKTIES AND USES. 183 have said, confined to the pharmacy of the Hakeems and Kobirajes, i.e. the Mohammedan and Hindoo physicians ; it is much used by Eiu'opean medical men, and I have given you most of the fonnulas in which it is administered. I will not occupy your time by much further detail on tliis subject, but may just say that, in addition to the authorities I have already mentioned, others have written on the subject, and if you care to do so you will find descriptions of the plant by Pereira in the Pliannaceutical Journal^ vol. x., page 165 ; by Sir R. Martin in the Lancet of July, 1853, page 53 ; by Dr. Horsefield in the " Transactions of the Batavian Physical Society," vol. viii., page 25, and by various learned authors of the last two centmies, such as Burmann, Bontius, Garcias ab Horto, and Caspar Bauhin. Descriptions of the plant and its uses are also to be found in the works of Roxburgh and Wight, Shortt, Newton, Green, Bose, Bidie, Pogson. In a paper entitled " Remarks on the Indian Bael or Bela in Dysentery, Chronic Diarrhoea, and Dyspeptic Disorders," by J. Aclolphus, published in London in 1853 ; also in " Notes on the Nature and Uses of the Indian Bael," by H. 0. Renfiy, London ; Bibl. Manchester Medical Society, 1855 ; also " Bael ou Bilva, Fruit de I'^gle Marmelos," A. CoUas, Revue Coloniak, August, 1856. Dr. Macnamara, late Pro- fessor of Chemistry in the Calcutta Medical College, has also recorded an examination of the fruit, in which he compares the ripe and the unripe fruit, in reference to the proportions of tannin or other astringent principles contained in each, and in which he states that the ripe contains more tannin than the unripe fruit, in the proportion of five to three. It contains more sugar, more of the bitter principle and vege- table acids not tannic. He obtained also, by means of ether, a balsam having a strong odour, closely resembhng that of Peruvian balsam. This exists in much larger quantities in the ripe than the unripe fruit. He says the astringent properties are due to tannic acid, and that the ripe fruit, containing more of this than tlie unripe fruit, is more potent. Dr. Macnamara suggests that the good effects of the bael may be due to the tannin and the balsam. His remarks on 184 ox TlIK llAKI- FRUIT, this head arc important : — " May not the astringent effects of the bael be due to the tone which it gives to the coats of the intestines, and to its balsam rendering the secretions of the mucous membrane more healthy ? It would then decrease the nimiber of stools in a dysenteric patient, or in an other- wise healthy one, but who is liable to mucous diarrhoea; while in a person of constipated habit, given to good feeding, bael might act as a laxative, by keeping the mucous secre- tions healthy, preserving the tone of the muscular coat, and so enabling the intestines, liable to irritation by peccant matters, to expel the crudities — nay, probably such people would be very liable to diarrhoea if they intermitted the bael ; and so, even with them, the bael may really be an astringent." Sir Jx. Martin, alluding to the composition of the bael, says in the Lancet, in regard to an analysis of the fruit by Mr. Henry Pollock, that " the pulp and the hard shell of the fruit do not appear to differ chemically in any respect except as to quantity. They both contain— (1) tannic acid; (2) a concrete essential oil ; (3) a bitter principle which is not precipitated by tribasic acetate of lead, and a vegetable acid. The pulp also contained a considerable quantity of sugar, in which it was preserved. All three of the substances I have mentioned exist in the largest quantities in the rind. There is most acid in the pulp." Many medical officers in India have used this remedy, and recommended it. The most instructive paper on the subject is one by Mr. A. G-rant, in the Indian Annals. Dr. Annesley, Dr. Jackson, Sir R. Martin, Dr. Waring, Dr. Duncan Stewart, Dr. E. Groodeve, Dr. Moir, Dr. Chuckerbutty, Dr. Cleghorn, and others have borne testimony to its value as a remedy in chronic dysentery, in diarrha3a, in some dyspeptic conditions, and in bowel complaints of children. I shall refer to some of their remarks on the subject, and then, in conclusion, briefly notice the conditions of disease in which I think the bael is likely to be useful in Europe. Mr. A. Grant says : — " Given in the form of sherbet it acts as an aperient to persons svibject to habitual constipation; AND ITS MEDICINAL PKOPEKTIES AN]1 ISES. 185 a small tumblerful taken in the morning will produce action of the bowels. In cases where dyspepsia is accom- panied by obscure symptoms of land-scurvy, it seems to act favoiu-ably, and produce alterative as well as antiscorbutic effects." To this I may add, on my own part, in the irregular action of the bowels, diarrhcea alternating with constipation, when the abdomen is distended, the appetite bad, the secre- tions defective, and the nervous system depressed, as one so often sees in the damp, tepid atmosphere of Bengal, espe- cially towards the end of the rains, when the mucous membrane of the intestinal canal is disordered and in a state of atony, the bael is not unfrequently an effective remedy, and, at all events, gives some relief, acting either as a laxative or tonic, according to circumstances, by stimulating the bowel to more healthy action, and, combining ^^-ith the ingesta, seems to promote digestion and assimilation. In the low and chronic forms of diarrhoea, among the weak and exhausted from whatever cause, whether as the sequel of malarious poisoning, fever, or dysentery, it may prove of benefit where opium and ordinary astringents have failed ; or it may be still more beneficial in combination with these remedies ; and Mr. Grrant saj^s that when he wanted to pro- duce a more stimulating effect in asthenic cases, he combined it with the tharrie or palm spirit. He mentions several cases of subacute dysentery successfully treated. Dr. John Jackson, Dr. Duncan Stewart, of Calcutta, and Sir E,. Martin have borne similar testimony to its utility, not only as an astringent, but as a preventive of diarrhoea in persons subject to that complaint, and also as a valuable agent in the treatment of some of the more chronic forms of dysentery. Dr. Jackson speaks favourably of its value in the treatment of the diarrhoea that sometimes follows cholera. Dr. Cleghorn says it has proved iiseful not only in obstinate diarrhoea, but in the irritability of the mucous membrane of the intestine that followed the expulsion of taenia by koussa. Mr. Sanderson, a distinguished medical officer of Madi'as, speaks well of it. Sir Iv. Martin made the follomng remarks : — " On what 18G ON TllK JiAKI, FRUIT, the curative property depends I know not ; it is certainly not astringent to the taste, or at all events very slightly so. I am inclined to believe that much of its efficacy may reside in the thick mucilage which sm-rouiids the seeds of the fruit. A singular property of the fruit is this, that it does not merely restrain undue action of the bowels, as in diarrhoea and dysentery, but also in cases of obstinate habitual con- stipation acts as a mild and certain laxative. It may in all cases be said to regulate the bowels." — Lancet, July, 1853, page 53. Dr. Moore, of the Bombay Medical Department, who, at the instance of Grovernment, has written a popular work on medicine, for the use of persons away from medical aid, for which he received the reward offered for the best essay, says : — " It acts as an astringent to the mucous membrane of the bowels, and is also slightly aperient, a union of qualities not found in other astringents. It is useful in chronic diarrhoea and dysen-tery." In the March number of the Indian Medical Gazette, I find the following remarks by an officer, who — as is often the case in India — being left to his own resom'ces for medical assistance, had been obliged to fall back on such knowledge as he had, or could gather from books, and treat as he best might the complaints occurring in natives or others who were serving under him in that particular locality. India is not a country for specialists, and men holding responsible offices are often obliged to be their own doctors. The writer is Colonel Parsons, Deputy Commis- sioner of Gujerat, in the Punjaub : — " My attention was first called to the subject some years ago by a brother officer, when I was stationed in a very damp district, where diarrhoea and dysentery were not uncommon complaints. I was myself attacked with the latter form of disease, which rapidly disappeared under bael treatment. Since then I have frequently been in localities where European medical officers were not always present, and I have suggested and administered the same remedy to both Europeans and natives suffering from either of the AM) ITS MEDICINAL PROrEKTIES AND ISES. 187 above complaints, and invariably the bael has caused most satisfactory results. " The subject of the use of bael is not by any means a new one, and I believe the fiiiit is extensively used for medicinal purposes by Presidency surgeons ; but as far as my experience goes, it might with great advantage be much more used in Upper India for the above complaints than it is at present. I feel siu'e that a great deal of mortaUty in English regiments from the scourge of dysentery would be saved by the free use of bael fruit, as I have foimd its effects absolutely marvellous, both as regards rapidity of action and effectual cure. I beheve that Pogson's preparation of bael was tried in the army ; but I am not aware whether it was considered efficacious. I did not find it of use. The fresh fruit is the best form, but that is not always procurable. I have, however, found Bathgate's dietetic bael all that could be desired, in the absence of the fresh fruit. The mode of administering the fresh frait I have always adopted is to strain the juice from the pulp through musHn, add a little water and sugar; it then makes a very palatable drink. Two baels a day (this applies to small ones), of the size of an orange, one in the early morning, the other in the evening, I have found sufficient to effect a cure in a very few days, provided animal food be avoided or very sparingly used." I might easily add to these notices in its favour, but it "v^■oldd be wearisome to do so. I will just remark that you may observe all tell much the same story, and declare it to be a valuable remedy in certain chronic diseased conditions of the ])i-ini(e rue ; but none regard it as a remedy for acute disease. It is a mistake, not unfrequently made, to give remedies at the WTong time ; and this is sometimes done in the ease of bael, which has been unjustly blamed for not doing that to which it never had any pretensions to do. As a remedy in clu'onic disease it may be of much value, but it is useless in the acute fomis. The conditions in which it is likely to be usef id in In