1847] Harty on Dysentery. 69 The causes capable of producing purpura hæmorrhagica much resemble those which induce scorbutus; and the symptoms of the two diseases are very similar. Both, too, may continue in a chronic condition for months. It is of importance to turn attention to the concomitant symptom of purpura, the hæmorrhage, which is not found in the early stages of scorbutus. The scorbutic synocha is distinguished from the purpura by a formication of the surface, the livid color of the gums and the fetid breath. Although there is much resemblance between the symptoms of petechial typhus and scorbutus, the skilful practitioner will easily distinguish them. The third stage of the latter has been called by some writers the typhoid stage, on account of the prostration into which the patient falls; but this may be easily distinguished from a true typhus, since, besides the state of the gums, the fætor of the breath, and the pains in the extremities, the scorbutic patient never loses his appetite, desiring even the most extraordinary articles of diet-while in typhus the most complete anorexia prevails. We consider that Dr. Novellis has produced a very creditable essay upon an interesting subject, and we only wish that he and his Italian brethren would furnish us with more frequent opportunities of making their acquirements better known to the practitioners of this country. OBSERVATIONS ON THE HISTORY AND TREATMENT OF DYSENTERY AND ITS COMBINATIONS; with an Examination of their Claims to a Contagious Character, and an Enquiry into the Source of Contagion in its analogous Diseases, Angina, Erysipelas, Hospital Gangrene, and Puerperal Fever. By William Harty, M.D., &c. 2nd Edition, 8vo. pp. 303. Hodges and Smith, Dublin, 1847. THE first edition of this truly valuable work was published more than forty years ago, and received a most favourable character from the leading medical Journals of that time: it was mentioned also with commendation by Sprengel in his Critical Review of Medicine. To most of the readers of the present day it has all the novelty of a new book; few are acquainted with it, and fewer still have learned to appreciate the value of the doctrines it propounds. To us it has a peculiar interest; and more especially at the present time, when we have been endeavouring to settle in some degree the opinions of our medical brethren on the important subject of Infection, as an attribute of certain diseases, and a cause of their propagation and diffusion. It is, indeed, most gratifying to find that so enlightened an observer as the author of the work now under review had long ago adopted and advocated, with no common ability, the same view of the question as we have sought to establish the sanction of such an authority goes far to confirm us in the accuracy of our own opinions. In alluding to the subject of Contingent Infection, in the last number of this Journal (p. 459), we gave expression to the following remark, in reference to the very disease upon whose true history Dr. Harty has happily thrown so much light: If the broad and general question, Is Erysipelas or is Dysentery infectious? were put to a physician, he might with perfect truth and propriety answer it in the affirmative; and yet all that he meant by such a response might be the simple declaration of his opinion that these diseases are occasionally or conditionally communicable from one person to another, although such an occurrence does not happen once in a thousand times, and only under very peculiar circumstances." In the present article we shall have an opportunity of explaining what is the nature of those circumstances, to which allusion was then made. In commencing our observations, we may remark that there is perhaps no malady on which there has been greater discordancy and contrariety of opinion as to many of its most important phenomena and attributes than Dysentery; and, judging from the observations of the very latest writers upon this disease, medical men scem to be nearly as far remote from settled or well-grounded opinions on some points, as ever. Dr. Copland has said with too much truth we fear-that, "our knowledge of the disease is but little in advance of what it was two centuries ago, and that even the most recent writers are distinguished rather by confined and exclusive ideas as to its nature and treatment than by comprehensive views of its forms and manifestations in connexion with the various combinations of causes producing it, and the diversified circumstances in which it prevails." And then he adds the philosophic remark :-" Exclusive notions of a disease are the result of a knowledge merely of what has occurred within the sphere of the author's observation; whilst more extended ideas are acquired from what he has remarked in various climates, on different occasions, and at distant periods, and from an acquaintance with what has been observed by others, believing, truly, that nothing is constant but change; that what has occurred or prevailed formerly will recur again; and that one form is as likely as another to appear in future, whenever the concurrence of causes, of which it is a necessary or contingent result, shall take place.". That writer but imperfectly performs his duty, who, in giving a history of a most dangerous malady, confines himself to the particular form it has assumed during a few seasons, within the single locality of which he is the centre, and argues that it is always as he observed it: thereby affirming as true of the genus, what may be hardly true of the species."* So much for one high authority; let us see what says another. In the last edition of the classical work of Dr. Johnson and Mr. Martin on the "Influence of Tropical Climates, &c." we read :-" There is hardly a disease in the whole range of nosology, regarding which so great a discrepancy among authors and practitioners has existed as in dysentery; and this must have originated, I conceive (says Dr. J.) in consequence of mistaking prominent effects for proximate causes; and, as the means of cure directed against the former have often removed the latter, each individual believed that he alone had found out the true cause and cure of the disease." * Dictionary of Practical Medicine, Vol. I., p. 701. 1847] Different Forms of the Disease. 71. But it is not so much in reference to the pathology and treatment of dysentery, as to its occasional attribute of infectiousness, that we have now to invite the attention of our readers. As upon this point, too, the utmost confusion still prevails, we sincerely trust that the present analysis of the instructive volume before us will be found to disentangle many of its perplexities. Dr. Johnson has, in the work just cited, given the weight of his authority in too unqualified a manner to the negative side of the question, resting his opinion solely and exclusively on the results of his own experience in a tropical country; where the disease, it is admitted, seldom exhibits an infectious character.* The most recent writer on Dysentery, Dr. Parkes (whose work† we noticed in our Number for October last), is more guarded in his opinion, and thereby more correct. "Contagion," says he, "undoubtedly does not act in common dysentery; but it is certain, if the statements of many esteemed authors are to be admitted as evidence, that, at times, in slave ships, and after some campaigns, or in beseiged cities, asthenic dysentery has become contagious, being then complicated with a low fever. This low or typhoid fever has been supposed by some to be the cause of the contagion; but to this is replied, why should the dysentery be always the resulting disease, and not the fever? But it is a question if contagious dysentery is ever seen separated from the accompanying fever; are not the two diseases always propagated together? Are there instances known in which pure uncomplicated dysentery, sthenic or asthenic, as the case may be, has been derived from a case compounded of dysentery and typhus ?" P. 132. Dr. Parkes is quite right in his conjecture that it is the association or conjunction of Typhus fever with Dysentery that renders the latter disease liable to become infectious. This point in its history Dr. Harty has elucidated far more ably and successfully than any writer, either before or since the publication of the first edition of his work. As we have said, his views have not hitherto been appreciated by the profession as they deserve. Had they been better known and understood, there would doubtless have been less wavering and discrepancy in the statements of many writers—and those, too, men of experience-during the course of the present century. The following three positions contain the pith and marrow of our author's opinions on the general history of the disease we are now considering :— 1st.-That the genuine and simple dysentery is unattended by idiopathic fever, and is never of itself contagious (infectious). 2nd.-That every form of the disease, when epidemic, is a combination of the simple dysentery either with intermittent, remittent, or continued fever; and, It would seem, however, from the following extract from the Medico-Chirurgical Review for October 1838, quoted by Dr. Harty, that Dr. Johnson did admit the occasional or contingent infectiousness of Dysentery. "We doubt much whether the disease is ever infectious per se, but only when it is an attendant on a low or typhoid fever, when the latter may prove infectious, and carry its intestinal character from person to person." + Remarks on the Dysentery and Hepatitis of India. 1846. 3rd. That the combination with continued fever alone is contagious (infectious). Having illustrated in, as appears to us, the most satisfactory manner, the truth of these conclusions, Dr. H. then proceeds to examine the subject of the Treatment of the different forms of Dysentery, pointing out as he goes along how necessary it is to have clear and accurate notions on the above pathological positions, if we hope to attain to anything like precision or accuracy in our therapeutic principles. Thus, the practical importance of the preliminary enquiry is rendered obvious, while, at the same time, fresh proofs of the accuracy of the conclusions arrived at are obtained from an examination of the remedies that have been found to be most useful at different times. The first Chapter is devoted to the consideration of Simple Dysentery. By this term our author wishes to be understood that species of the disease in which the intestinal symptoms-viz. severe tormina of the bowels, frequent dejections of a mucous and bloody character, accompanied with a most distressing tenesmus-are not necessarily associated with any form of idiopathic fever. That fever is not an essential accompaniment of Dysentery, is abundantly obvious from the observations of some of the most accurate describers of the disease. Sydenham states that, in the majority of cases, which came under his notice, the gripes attack first, and the purgings succeed, without being preceded by any fever. Akenside* asserts that dysentery is very rarely attended by fever, not once in ten cases of the disease. Stollf too, when speaking of the rheumatic-bilious form of the disease, says, "febre quidem evidenti carebat, non omni tamen motu febriculoso." Roederer says, "fever was either altogether absent, or it set in only after the disease had existed for some time: few patients sickened from the first with febrile symptoms." M. Vignes|| also, when describing the dysentery prevalent in the French army encamped around Vienna in 1809, states that, in the Spring, "in several cases we noticed the prevalence of slight fever, but in the majority there was none at all. In the latter the symptoms were always less severe, than in the former." As the season advanced and numbers increased, the dysentery began to be complicated with typhus, adynamia, ataxia, or nervous fever, which prevailed epidemically throughout the army; it spread also amongst the inhabitants of the country. Among the latter, however—and this is a fact especially well worthy of notice-the disease appeared only under the characters of the fever, the dysenteric symptoms not occurring in them." From this circumstance, M. Vignes infers that the intestinal affection was generally owing to the exposure to inclement and variable weather, excessive fatigue, and the insufficient or irregular supply of food; from all which evils, the soldiers in the French army suffered more severely than the people of the country. Franks also, who had very ample experience * De Dysenteria Commentarius. Lond. 1764. Traité Complet de la Dysenterie. Paris, 1825. § Epitome de Curandis Hominum Morbis. Lib. v. de Profluviis. Vien. 1807. 1847] Affinity between Dysentery and Rheumatism. 73 in the disease, states that "in numerous cases there is no shivering nor feverish heat at its commencement, no loss of appetite is experienced, and there is scarcely any perceptible acceleration of the pulse." Dr. Parkes, too, says :—“ In some particular forms there may be attendant feverishness; but in the majority of cases there is no pyrexia, in the common acceptation of the term. Often there are no rigors or pains in the limbs, or any affection of the general health.” The passages we have now quoted-and their number might easily be multiplied threefold-will sufficiently serve to shew that fever is not a necessary or essential accompaniment of an attack of dysentery. That a greater or less degree of febrile excitement very generally supervenes, if the symptoms be not immediately arrested, will be denied by no one; but this is very different from fever being supposed to constitute one of the primary characters of the disease. Hence its definition, given by Cullen, is clearly erroneous. It stands thus :-" Pyrexia contagiosa; dejectiones frequentes, mucosæ, vel sanguinolentæ, retentis plerumque facibus alvinis; tormina, tenesmus.” We shall not now allude to the (alleged) fever being here declared to be always infectious; as this subject will engage our attention in the sequel. Akenside's descriptive definition is altogether more accurate :-" Qui graviora patitur ventris tormina, simul cum frequente desidendi cupiditate, et cum dejectionibus vel sanguineis vel mucosis (vel utrisque), eum hominem Dysenteria laborare omnes consentiunt medici.” Simple Dysentery is very generally the result of exposure to wet and cold in the months of Summer or Autumn, more especially when this most prolific cause of disease is aided by the use of unwholesome or insufficient food, acid unripe fruits, pernicious drinks, and, in short, of whatever has a tendency to induce irritation of the mucous surface of the bowels. Almost all sporadic cases of the malady belong to the simple form now described; and instances of it are also far from uncommon in every epidemic, whatever be the prevailing type of the fever by which the epidemic may be characterised. Before proceeding to notice those forms of the disease which arise from a combination of the intestinal affection with fever of different types, Dr. Harty devotes a chapter to illustrate the Affinity between Dysentery and Rheumatism. "The opinion that there exists an intimate connexion between these diseases, first suggested by Alexander of Tralles (who called dysentery a rheumatism of the intestines), has in modern times been adopted by Akenside, Richter, Stoll, and others. Independently of the authority of these writers in favour of this doctrine, we find in other authors a few scattered facts, which must carry the greater weight, as they are recorded by individuals unbiassed by any theory on the subject." P. 22. Akenside states that he often observed rheumatism to supervene upon the decline of dysentery and vice versá, that occasionally the two diseases exist together, and that both disappear under the same line of treatment. Every physician must have remarked that the stools in the former disease often exhibit the dysenteric character, consisting almost entirely of mucus, and attended with griping pains and distressing tenesmus.* * Daily experience shews that not only rheumatic, but gouty disease also, is |