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3/5/1856: Dr. Samuel Mudd's Medical Graduation Thesis
Source: University of Maryland, Health Sciences and Human Services Library, Baltimore, Maryland.
The University of Maryland’s Medical Department in the 1850s was, and still is today, one of the country’s leading medical schools. The instruction Dr. Mudd received was the best available to medical science at the time. However, medical science then did not have the knowledge we do today of bacterial infection, or the antibiotics to treat such infections. Dr. Mudd’s graduation thesis on dysentery provides a fascinating insight into the state of medical knowledge in the mid 1800’s. Almost none of it would be applicable today.
An Inaugural Dissertation on Dysentery Submitted for Examination of the Provost, Regents and Faculty of Physic of the University of Maryland for the Degree of Doctor of Medicine by Samuel Alex. Mudd.
Dysentery
Dysentery - a disease which is common to nearly every clime - is found to prevail with unrelenting severity during some seasons - bidding defiance to the most active medical treatment and skill; at others mild and under the control of simple medical agents and care. It is a disease which visits impartially the man of wealth as well as the man of poverty - the man of authority - as well as the subject. It, like the avenging Angel of the Almighty Being, has been the instrument to humble the pride of nations. Armies have been attacked and thousands, like the leaves of the forest on the approach of the first autumnal frost, have faded, withered and fallen to the dust. The fireside has been made desolate, the orphan’s cry has been heard to utter the sweet but sad accents of grief, Where is my mama? Where is my papa? The wife’s brow is bedewed with a tear at the loss of her kind and grief soothing husband, or the tender offspring of her bosom, and the husband made wretched and weary of living, on account of its too cruel visitation, but enough of unimportant and tedious detail.
The characteristic symptoms of dysentery are first, griping pains in the abdomen, followed sometimes and very often by diarrhoea, which soon develop itself into frequent discharges of mucus and blood - with spasmodic action of the muscles engaged in defecation straining and tenesmus. The disease however just as commonly burst forth without the least complication. The first intimation the patient has of his situation is probably by one or two shooting pains across the abdomen, with a desire to stool, which after a somewhat fruitless attempt, nothing but a little mucus, he returns and in a short time is called again and again with about the same result, with the exception probably of a little addition of blood. Sometimes hard lumps of feces called scybala are thrown out combined with the mucus or blood, which seems to be the exciting cause - or more likely there seems to be a retention of the natural feces, which are occasionally expelled in small hard lumps, with their surfaces lubricated with the prevailing mucous evacuations. This mucus packets within the folds of the intestine, near the anus, which the first efforts at defecation throws out and all further attempts and desires for expulsion are in vain. This was the case with several patients that came under my observation and attention whilst a resident of the Baltimore Infirmary. The rectum from irritation produced by inflamation contracts upon itself involuntarily and spasmodically, and the only way apparently that the contents of the alimentary canal gain exit is by its gravitation.
Dysentery consists in inflamation of the mucous membrane of the colon and rectum. It may be either acute or chronic, both of which may occur independently of the other.
The acute form in its incipiency may be ushered in suddenly with active hemorrhagic discharges from the bowels as a diarrhoea, with tormina and tenesmus followed by inflamation of the above named intestines. It sometimes manifests itself in a periodic form - occurring at regular intervals with griping pains etc., and the stools may consist either of bloody mucous or serous - this variety is called the intermitting form of the disease or the disease may come on superadded, the derangement of the functions of the liver, spleen and stomach, especially those that reside in malarious districts, which has been termed the bilious or remittent type. Of these I shall hereafter speak.
The most marked symptoms in the acute form are uneasiness in the abdomen, griping pains, with tormina and tenesmus, hot and tender abdomen over the courses of the colon and rectum. The stools are bloody, mucous, foetid, dark coloured, and contain lumps of a pultaceous character, that is, when they contain faecal matter. At other times there is a great desire to stool, and when the patient is in the act, he is seized with great pains - and a vain attempt to pass more than half an ounce of bloody mucus, of a gelatinous nature, without the least trace of faecal matter.
Dysentery may set in with or without precursory symptoms. In the former case, it is preceded by general uneasiness, lassitude, impairment of the appetite, dull or transient pains in the abdomen, costiveness or diarrhoea, and other evidences of moderate intestinal irritation. Sometimes the local symptoms make their appearance before the general, and in mild cases may run its course without fever. Then again the local and febrile phenomena commence simultaneously - the patient being attacked with a shivering of the frame almost as soon as he complains of pain and tenesmus. Again the fever often precedes, and occasionally for a considerable period any evidences of disorder of the bowels.
The disease prevails from a very slight affection, implicating but a very small extent of the colon and rectum, passing off in two or three days, but sometimes owing to a peculiarity of the constitution, or to some great malignancy of the poison, the system receives a shock which the powers of life are scarcely able to react. Or after the disease has gone on for sometime, unaided by medical treatment or neglect, all the powers of the frame will sink down into a typhoid or collapse condition, or a general depression of the vital forces - livid lips, the eyes sunken, circumscribed by a bluish tint, with delirium, hiccough and finally death terminates his mortal existance. Such cases occur but seldom; principally observed by large and experienced practitioners to prevail during epidemic. I have seen but one case in which all these symptoms were developed. The patient from the beginning was attended by two eminent and talented physicians, who did all that the case seemed to require but to no avail - the system never recovered from the first shock.
The nature of the stools in the beginning, consist somewhat of a transparent whitish mucus, or of mucus streaked with blood and a little faecal matter, which may be altered by bile, small portions of false membranes and coagulated lymph. It is this decay of animal matter combined with vitiated secretions, or secretions undergoing decomposition no doubt that gives this peculiar disagreeable fetor to the discharges. Though this does not occur generally until the disease has gone on for two or three days, at which time in severe or moderately severe cases, there is nearly entire suspension of the natural stool. The inflammation if not checked will gradually and sometimes rapidly extend along the courses of the colon and rectum, the extent of which may be pretty accurately ascertained by percussion or pressure over those parts. If there is much tenderness over the epigastrium and right side we may conclude that the whole of the large intestines are involved or the inflamation has reached the transverse and ascending colon.
There is also tympanitis very often of the abdomen, principally over the regions of the colon - owing to the accumulation of flatus. When this takes place, there is more or less high fevers, the pulse full hard and quick, the skin dry and hot, the tongue coated with a whitish fur, and the stomach, liver, kidneys, bladder, urethra sharing in the general disorder - producing emesis, strangury, and painful micturation, and in females the vagina sympathises.
As a general rule the disease takes a healthy turn about the eighth or ninth day - danger in ordinary cases is increased from neglect or when the disease continues for a week or ten days without any moderation - the symptoms before spoken of are apt to become developed, and if the patient does not perish immediately, the chronic form with all its sequences are very likely to supervene, and from its constant drain upon the system the patient sikns or complete recovery may take place, but in agravated cases most commonly end fatally. In the latter stage of the disease, the discharges become very offensive and resembles the washings of fresh meat. I recollect seeing a patient troubled with a chronic mucoid discharge, which he said lasted for five years, scarcely without any intermission, and were increased whenever he was imprudent or indulged in his usual diet. which consisted principally of milk and mush, tea, toasted bread soaked in water, chicken and broth, soups, etc.
Chronic Dysentery - commonly follows the acute form - when it occurs independently it is generally associated or complicated with chronic enteritis. It sometimes though rarely proceeds from fistula in ano and hemorrhoidal - tumours - the inflammation being extended.
The principal symptoms in this form consist in the stools being less frequent, more feculent, mingled with mucus, tormina generally only when pressure is made and less tenesmus than in the acute. There is scarcely any perceptable difference in the skin, pulse, and indeed general health of the patient in chronic dysentery and chronic enteritis. After the disease has continued for a time, signs of hectic fever, or the various hydropic affections are very likely to come on in consequence of the system becoming prostrated through the excessive evacuations, depraved nutrition, secretions, deposits, etc. The membranes are also very apt to become thickened and the patient sooner or later falls a victim.
The Bilious form - in regard to the bilious form, there is nearly always functional disorder of the organs - the liver may fail to secrete, or it may over secrete the natural healthy supply of bile, but most commonly there is supression. The bilious secretions may precede, supervene or coexist with the disease, as a general rule however, they are present in the beginning, and arise very probably from the same cause that lights up the inflamation in the intestines. But in the simple and mild cases, where apparently, and no doubt the disease sometimes is produced by indegestible articles of food, or from the irritation that follows active diarrhoea from the bowels the derangement of the functions of the liver and stomach seems to depend upon sympathy. The symptoms that most commonly mark this form of the disease is epigastric oppression, vomiting, yellowness of the skin and conjunctiva, the tongue coated with a yellow brown surface with its borders red, and diminished secretions of bile and urine. The fevers are higher and a greater tendency to delirium.
The remittent character of the disease prevails chiefly in malarious districts, and is known by the marks of remittent fever being blended with it. There is constant fever with exacerbations and remissions, the tongue coated with a whitish fur generally and dry, the skin dry and hot. The stomach is more irritable than in any of the other forms - vomiting is more constant and the ejectment of bilious matter more common.
Sometimes the disease from the beginning assume the typhoid character, with sinking of all the powers of the frame and when apparently on the brink of eternity, the system reacts and convalescence takes place. Then again death may be the result, though it most usually run a regular course and terminates favourably under judicious treatment.
The intermitting form is very common in some sections of the country and like its kindred affection, remittent fever, prevails in malarious districts. It is a very interesting malady, and consist in a perfect intermission, occurring at regular intervals with all the symptoms in the acute form, lasting two or three hours, when they subside with a langour, the consequence of the paroxism. These paroxisms may be either of the quotidian, tertian, or quartan variety. There is a disease very much resembling this viz intermitting diarrhoea, and it is sometimes very difficult to discriminate between the two, the evacuations in both being somewhat serous, though there is one great mark or distinction. In the intermitting diarrhoea, there is no straining and tenesmus, and often but little tormina; but in the dysentery there is all or nearly all of the signs of the real disease in the acute stage present, viz straining, tenesmus, tormina, bloody and mucous stools, etc.
The causes of the disease are various, but for the most part, especially that which gives rise to the epidemic character, is unknown and unaccountable. Dysentery prevail epidemically or sporadically - epidemically where a whole district or section of country is simultaneously affected - sporadically where the disease arises from imprudence, or where a single individual is attacked. The contagiousness of the disease is doubted, and thus far the opion of the profession tends to the negative.
It has been observed by numerous authors, that persons exposed to all states of the atmosphere, subject to great variations of temperature, of heat, cold, wet and dry - persons traveling a long distance in hot and moist weather, or labouring people are apt to contract the disease. Those that are subjected to the same epidemic influences as give rise to remittent and intermittent fevers, are said to be more susceptable than those that are remote from its cause.
One of the most common reputed causes for its production on the Western shore of Maryland is the imprudence in eating unripe and acid fruits, such as apples, cherries, grapes etc. In eighteen hundred and fifty-three, nearly every family in my district, eight or ten miles around probably suffered from this malady and nine cases in ten the patients had indulged in eating cherries - there being quite an abundant crop that year.
Another and what appears to be more of an exciting than a productive cause is the sitting down upon wet and cold ground, thus armies and travellers, being often necessitated to sleep out with scanty insufficient clothing and food have been attacked by dysentery and thousands have fallen victim to its rage. Again, it exists epidemically without giving the least perceptable cause for its prevalence, and I have known men who were considered scrupulously exact in regard to their diet and habits to be seized with the disease, with as much violence, as those with some reputed cause might be adduced. Then again on the other hand I have known persons who have indulged in every species of luxury, such as eating all kinds of unripe fruits, drinking to excess all kinds of liquors, and exposing themselves to all kinds of harsh and inclement weather, to escape its influence. Drinking of cold water by workmen in warm weather seems to be one of the means by which the distemper is lighted into action; and I have known six out of twelve in the harvest field to be seized, where no other cause could be ascertained, with the exception probably of a little whiskey, which the farmers during those occasions are in the habit of furnishing to labourers.
The eating of indigestible articles of food also seems to be one of the sources by which the disease is set up, but during its prevalence, or where the nature of the malady is epidemic many simple and foolish causes of its production are mentioned, but it appears as often without as with a cause.
The treatment of acute dysentery - In mild cases where the patient only suffers from frequent evacuations, with but little tormina and tenesmus, unattended with fever, and where the contents of the abdomen expelled consists the greater part fecal matter - little or no treatment is required - rest, low diet generally in such cases being sufficient to effect a cure, though we should never rely on this, for very often the mildest cases are prolonged and even prove fatal in consequence of paying too little regard to the state of the patient. Very often when the disease commences with symptoms of diarrhoea it may in many cases be cut short by a simple glass of brandy, or any common astringent, combined with rest and resisting the inclination to stool as much as possible.
But in the more severe forms, where the tormina and tenesmus gain the ascendancy of the will, where the stools are of a mucous purulent and bloody character, where the skin is hot and dry, the tongue coated and associated with these, fever - active medical treatment must be pursued or adopted. If the patient be of a plestoric, robust habit, general bleeding in most instances has a marked tendency to put a stop to, or to decrease the violence of the malady. After this I have observed in those cases that have come under my charge - that small doses of chloride of mercury, combined with opium and ipecacuanha, act very beneficially by calming the irritation, improving the condition of the skin and secretions - together with its antiphlogistic prpoerty - check the inflammation. This is equally applicable in cases after or in the absence of bleeding. It is well in most cases to continue this prescription for twenty four or forty eight hours, giving it at intervals of every four hours, watching its effects, and suspending its employment, when symptoms arise contraindicating its use. The dose in such examples might be given in proportions of proto chlorid. hydrarg. ipecac. of each three to five grains and opium one. Ipecacuanha is said by some to act remedially by lessening the peristaltic motion of the intestines with its revulsive agency.
Another very excellent remedy, after the employment of mercury of in cases where it is not required is the acetas plumbi and opium in equal parts made into pill - one or two or more through the day according to the effects they produce, or as the case may seem to require. To be sure this ought to be the rule and the duty of every prudent physician. It is hard to say what should be the treatment without the case is presented to our view. We always minister to the symptoms and not to the name of the disease, for otherwise gross errors and sad consequences would be the result. There is no agent in the Materia Medica that deserves more praise than the judicious employment of mercury. I have seen well marked cases that have been cured where no other medicine has been used, with the exception of an ounce or two of ol. recini.
Equal to, or next in efficacy is opium. Without this agent our attempts in many cases at cure would be fruitless. We have no other remedy in which there is connected so many important requisites towards the restoration to health in this disease. It seems in every stage to be applicable, and but a few in which it is contraindicated. Yet in those which it appears unfit, it sometimes produces opposite effects - as in cases of hot and dry skin, tongue and fauces, the very effect in the healthy subject it produces, this symptom is very often and frequently entirely relieved by the action of this article.
A very good domestic astringent, which in many parts of the country is very convenient, is made by taking equal parts or quantities of red oak bark, pine tops or branches and ground olive. I have seen this used by persons with the approbation of the physician with the best results, also the common running brier root, made by boiling one or two ounces of the root with a pint of water, which is generally called brier root tea; in order to make it more palatable, it may be slightly sweetened, and the patient may take one, two or three ounces at a time during the day as an ordinary drink.
In the more advanced stage of the disease, where there exists a pretty considerable erethism, anxiety about the praecordia nausea and vomiting, the countenance pale and anemic, the tongue red, the abdomen tumid, distended with flatus and painful to the touch - discharges, foetid, consisting chiefly of blood and mucus.
The best mode of procedure in this instance would be cups or leeches over the abdomen, along the courses of the colon, or inflamation. In the latter stage of dysentery, the best agent known to relieve the distended and tumid abdomen is the oleum Lerebinthinae. This I have seen used often in drachm doses with the greatest satisfaction to the patient and physician.
Opiates internally by way of the mouth, or injection per rectum, demulcent drinks; and when the system is very feeble and prostrated, the diet should be nutritious, and to subserve this purpose, beef tea answers our intention the best.
The action of opium sometimes in this and similar effections varies from its general. It often acts as a purgative secondary by destroying the spasm and irritation consequent upon the inflamation, thus allowing the retained faeces to pass without obstruction, or the opium relieving the strangulation, thus allows the purgatives to act.
We treat all the various forms upon the same general principal - to check inflamation where it is present, to build up the system when the powers of life are declining by nutritious diets and stimulants, to relieve congestion and promote the secretory and excretory functions of the organs, and lastly, but not least, after we have done all to the best of our knowledge to relieve, leave the balance for nature to accomplish.
In the bilious forms we cannot do well without mercury, the liver very often being much deranged in its functions - we will in some cases have to be quite persistent in its use, then again it may be of no utility. In those cases where there is an over secretion and excretion - that is it may not be primarily of any service, but secondarily by correcting the morbid condition in other parts of the body.
In the remittent and intermittent types, Lumia, combined when the patient is aenemic with some of the ferruginous tonics and gentle purgation is all that is necessary to eradicate the disease.
In the chronic stage the best mode of treatment depends upon our attention to diet and regimen - for without this precaution, it is vain to expect a cure. In this stage the patient sooner or later becomes aenemic, thus indicating the replacing properties of the iron, which may be given in doses from a half to a grain of the sulfate two or three times a day. A very good combination of articles to prevent the hemorrhage from the bowels and supply the colouring material in the asthenic and aenemic, consist in Creta. praep., Ferri. Ferrocyan., Ext. haematoxylon, Opii grs.iij, cinna., vj grs., sach alba si, made into eight powders, of which one may be taken every three or four hours. If the case be a bad one, there may be used in conjunction of acetas plumbi grains ten and opium one or two, administered once or twice a day, according to the symptoms and effects.
We may also follow, when the disease is determined and obstinate the acetate of lead and opium pill every two, three, or four hours and if it does not succeed in arresting the symptoms, the nitras argenti pill or sulphate of copper in quantities varying from a half to a grain and a half at the same intervals, and if signs of ulceration come on the two latter named substances may injected per rectum in larger doses.
Prognosis. When the disease is about to end in convalescence, all the symptoms become more mild. The tormina and tenesmus diminishes, the stools become more fecal, larger and less frequent, or there is a general subsidence of all the marks of the disease, and nothing for the most part left, except a moderate diarrhoea, which passes off in the course of a few days. The patient sometimes though not often - after all signs of the disease has gone off - complain of cramps, which come on once or twice a week suddenly, and during their continuance causes great suffering.
But on the contrary, if there should supervene, tympanitis, high fevers with quick and weak pulse, following this, a cold clammy sweat, with coldness of the extremities, the features sunken and depressed, with a purplish hue of the skin, especially about the eyes, mouth and the tips of the fingers - attended with hiccough delerium, subsultus tendinum etc., we conclude that these are omens which portend an unfavorable termination.
Danger in this disease as in all others, is proportionate to the extent of the inflamation. If we ascertain on pressure that the whole of the colon is involved, our attention should be directed with watchful anxiety, and unless means be adopted to check the inflamation and the irritation thus produced - in a large majority of cases the powers of life will sink and the disease end fatally. In Sporadic dysentery - where the patient is well attended to, there is not so much to dread - nearly always yielding to the influence of medical agents and means. But in the epidemic character, we should never be too sanguine for I have known mild cases to occur in young subjects with constitutions strong and robust, and have been in the care of the best physicians, who persued the regular treatment with all its activity, without success.
Anatomical Characters - The lining membrane or the mucous coat of the lower and sometimes of the whole extent of the colon and rectum shows marks of inflamatory action after death. It has been observed where the irritation has been transmitted from the large to the small intestines, the solitary or Brunners glands found in the curvatures of the stomach and duodenum have been found considerably engorged and distended with evident signs of inflamation. There is also a condition existing very much resembling the lesions produced by typhoid fever, the mesentery and the glands of Peyer presenting nearly the same aspect. Ulceration in this disease is more common than any other, except probably that of typhoid fever - the appearance of which presents a smooth surface, or edge coated very often with the membranes that are frequently ejected during the evacuations, such as false membranes, coagulated lymph, etc. There again there have been instances cited where actual mortification and sloughing in the parts have taken place.
Thickening of the coats of the intestines also is produced, and I remember seeing a post mortem examination of a case resulting from this disease in which there was stricture of the colon - the opening so small that the little finger could scarcely be introduced - it was bound down by a thick, firm muscular band.
Various other lesions resulting from a scrupulous taint of the system, stinty diet, depraved nutrition, residing in badly ventilated departments, exposure, etc. have been noticed as producing a dissimilar anatomical lesion. In climates within the trophics the liver is frequently found diseased with hepatic abscesses etc.
In conclusion, let me remark - that in appreciating the moral and scientific lessons and instructions in the art of medicine - delivered by those who have given us practical and theoretical illustrations in the guide of the knife, when it was required, and its utter repugnance when no good could be effected - by those who have taught us practically the true method of searching out disease, and when we have found it, to administer the indicated soothing or healing agent - by those who have marked out the path to the most vital organs, that in case of accident or from a morbid action going on in the system, it may be in our power to apply the ligature or the barrier to death by those who have instructed us in the nature and action physiologically of articles contained in the Materia Medica, as observed by practitioners from their experience in the healing art, and from experiments on the lower order of animal beings, and finally - by those who have acquainted us with the means whereby we can detect fraud and the hypocricy of the assassin when under the cloak of medical agents,
I can only express my sincere thanks, and only hope that the knowledge derived from your wise teachings may prove a credit to the institution in your behalf and my future reward. Wishing that this badly gotten up preamble may meet with your approbation, I respectfully conclude with bright anticipations of being numbered with the profession.
Yours, etc.
Saml. A Mudd
Dysentery
Dysentery - a disease which is common to nearly every clime - is found to prevail with unrelenting severity during some seasons - bidding defiance to the most active medical treatment and skill; at others mild and under the control of simple medical agents and care. It is a disease which visits impartially the man of wealth as well as the man of poverty - the man of authority - as well as the subject. It, like the avenging Angel of the Almighty Being, has been the instrument to humble the pride of nations. Armies have been attacked and thousands, like the leaves of the forest on the approach of the first autumnal frost, have faded, withered and fallen to the dust. The fireside has been made desolate, the orphan’s cry has been heard to utter the sweet but sad accents of grief, Where is my mama? Where is my papa? The wife’s brow is bedewed with a tear at the loss of her kind and grief soothing husband, or the tender offspring of her bosom, and the husband made wretched and weary of living, on account of its too cruel visitation, but enough of unimportant and tedious detail.
The characteristic symptoms of dysentery are first, griping pains in the abdomen, followed sometimes and very often by diarrhoea, which soon develop itself into frequent discharges of mucus and blood - with spasmodic action of the muscles engaged in defecation straining and tenesmus. The disease however just as commonly burst forth without the least complication. The first intimation the patient has of his situation is probably by one or two shooting pains across the abdomen, with a desire to stool, which after a somewhat fruitless attempt, nothing but a little mucus, he returns and in a short time is called again and again with about the same result, with the exception probably of a little addition of blood. Sometimes hard lumps of feces called scybala are thrown out combined with the mucus or blood, which seems to be the exciting cause - or more likely there seems to be a retention of the natural feces, which are occasionally expelled in small hard lumps, with their surfaces lubricated with the prevailing mucous evacuations. This mucus packets within the folds of the intestine, near the anus, which the first efforts at defecation throws out and all further attempts and desires for expulsion are in vain. This was the case with several patients that came under my observation and attention whilst a resident of the Baltimore Infirmary. The rectum from irritation produced by inflamation contracts upon itself involuntarily and spasmodically, and the only way apparently that the contents of the alimentary canal gain exit is by its gravitation.
Dysentery consists in inflamation of the mucous membrane of the colon and rectum. It may be either acute or chronic, both of which may occur independently of the other.
The acute form in its incipiency may be ushered in suddenly with active hemorrhagic discharges from the bowels as a diarrhoea, with tormina and tenesmus followed by inflamation of the above named intestines. It sometimes manifests itself in a periodic form - occurring at regular intervals with griping pains etc., and the stools may consist either of bloody mucous or serous - this variety is called the intermitting form of the disease or the disease may come on superadded, the derangement of the functions of the liver, spleen and stomach, especially those that reside in malarious districts, which has been termed the bilious or remittent type. Of these I shall hereafter speak.
The most marked symptoms in the acute form are uneasiness in the abdomen, griping pains, with tormina and tenesmus, hot and tender abdomen over the courses of the colon and rectum. The stools are bloody, mucous, foetid, dark coloured, and contain lumps of a pultaceous character, that is, when they contain faecal matter. At other times there is a great desire to stool, and when the patient is in the act, he is seized with great pains - and a vain attempt to pass more than half an ounce of bloody mucus, of a gelatinous nature, without the least trace of faecal matter.
Dysentery may set in with or without precursory symptoms. In the former case, it is preceded by general uneasiness, lassitude, impairment of the appetite, dull or transient pains in the abdomen, costiveness or diarrhoea, and other evidences of moderate intestinal irritation. Sometimes the local symptoms make their appearance before the general, and in mild cases may run its course without fever. Then again the local and febrile phenomena commence simultaneously - the patient being attacked with a shivering of the frame almost as soon as he complains of pain and tenesmus. Again the fever often precedes, and occasionally for a considerable period any evidences of disorder of the bowels.
The disease prevails from a very slight affection, implicating but a very small extent of the colon and rectum, passing off in two or three days, but sometimes owing to a peculiarity of the constitution, or to some great malignancy of the poison, the system receives a shock which the powers of life are scarcely able to react. Or after the disease has gone on for sometime, unaided by medical treatment or neglect, all the powers of the frame will sink down into a typhoid or collapse condition, or a general depression of the vital forces - livid lips, the eyes sunken, circumscribed by a bluish tint, with delirium, hiccough and finally death terminates his mortal existance. Such cases occur but seldom; principally observed by large and experienced practitioners to prevail during epidemic. I have seen but one case in which all these symptoms were developed. The patient from the beginning was attended by two eminent and talented physicians, who did all that the case seemed to require but to no avail - the system never recovered from the first shock.
The nature of the stools in the beginning, consist somewhat of a transparent whitish mucus, or of mucus streaked with blood and a little faecal matter, which may be altered by bile, small portions of false membranes and coagulated lymph. It is this decay of animal matter combined with vitiated secretions, or secretions undergoing decomposition no doubt that gives this peculiar disagreeable fetor to the discharges. Though this does not occur generally until the disease has gone on for two or three days, at which time in severe or moderately severe cases, there is nearly entire suspension of the natural stool. The inflammation if not checked will gradually and sometimes rapidly extend along the courses of the colon and rectum, the extent of which may be pretty accurately ascertained by percussion or pressure over those parts. If there is much tenderness over the epigastrium and right side we may conclude that the whole of the large intestines are involved or the inflamation has reached the transverse and ascending colon.
There is also tympanitis very often of the abdomen, principally over the regions of the colon - owing to the accumulation of flatus. When this takes place, there is more or less high fevers, the pulse full hard and quick, the skin dry and hot, the tongue coated with a whitish fur, and the stomach, liver, kidneys, bladder, urethra sharing in the general disorder - producing emesis, strangury, and painful micturation, and in females the vagina sympathises.
As a general rule the disease takes a healthy turn about the eighth or ninth day - danger in ordinary cases is increased from neglect or when the disease continues for a week or ten days without any moderation - the symptoms before spoken of are apt to become developed, and if the patient does not perish immediately, the chronic form with all its sequences are very likely to supervene, and from its constant drain upon the system the patient sikns or complete recovery may take place, but in agravated cases most commonly end fatally. In the latter stage of the disease, the discharges become very offensive and resembles the washings of fresh meat. I recollect seeing a patient troubled with a chronic mucoid discharge, which he said lasted for five years, scarcely without any intermission, and were increased whenever he was imprudent or indulged in his usual diet. which consisted principally of milk and mush, tea, toasted bread soaked in water, chicken and broth, soups, etc.
Chronic Dysentery - commonly follows the acute form - when it occurs independently it is generally associated or complicated with chronic enteritis. It sometimes though rarely proceeds from fistula in ano and hemorrhoidal - tumours - the inflammation being extended.
The principal symptoms in this form consist in the stools being less frequent, more feculent, mingled with mucus, tormina generally only when pressure is made and less tenesmus than in the acute. There is scarcely any perceptable difference in the skin, pulse, and indeed general health of the patient in chronic dysentery and chronic enteritis. After the disease has continued for a time, signs of hectic fever, or the various hydropic affections are very likely to come on in consequence of the system becoming prostrated through the excessive evacuations, depraved nutrition, secretions, deposits, etc. The membranes are also very apt to become thickened and the patient sooner or later falls a victim.
The Bilious form - in regard to the bilious form, there is nearly always functional disorder of the organs - the liver may fail to secrete, or it may over secrete the natural healthy supply of bile, but most commonly there is supression. The bilious secretions may precede, supervene or coexist with the disease, as a general rule however, they are present in the beginning, and arise very probably from the same cause that lights up the inflamation in the intestines. But in the simple and mild cases, where apparently, and no doubt the disease sometimes is produced by indegestible articles of food, or from the irritation that follows active diarrhoea from the bowels the derangement of the functions of the liver and stomach seems to depend upon sympathy. The symptoms that most commonly mark this form of the disease is epigastric oppression, vomiting, yellowness of the skin and conjunctiva, the tongue coated with a yellow brown surface with its borders red, and diminished secretions of bile and urine. The fevers are higher and a greater tendency to delirium.
The remittent character of the disease prevails chiefly in malarious districts, and is known by the marks of remittent fever being blended with it. There is constant fever with exacerbations and remissions, the tongue coated with a whitish fur generally and dry, the skin dry and hot. The stomach is more irritable than in any of the other forms - vomiting is more constant and the ejectment of bilious matter more common.
Sometimes the disease from the beginning assume the typhoid character, with sinking of all the powers of the frame and when apparently on the brink of eternity, the system reacts and convalescence takes place. Then again death may be the result, though it most usually run a regular course and terminates favourably under judicious treatment.
The intermitting form is very common in some sections of the country and like its kindred affection, remittent fever, prevails in malarious districts. It is a very interesting malady, and consist in a perfect intermission, occurring at regular intervals with all the symptoms in the acute form, lasting two or three hours, when they subside with a langour, the consequence of the paroxism. These paroxisms may be either of the quotidian, tertian, or quartan variety. There is a disease very much resembling this viz intermitting diarrhoea, and it is sometimes very difficult to discriminate between the two, the evacuations in both being somewhat serous, though there is one great mark or distinction. In the intermitting diarrhoea, there is no straining and tenesmus, and often but little tormina; but in the dysentery there is all or nearly all of the signs of the real disease in the acute stage present, viz straining, tenesmus, tormina, bloody and mucous stools, etc.
The causes of the disease are various, but for the most part, especially that which gives rise to the epidemic character, is unknown and unaccountable. Dysentery prevail epidemically or sporadically - epidemically where a whole district or section of country is simultaneously affected - sporadically where the disease arises from imprudence, or where a single individual is attacked. The contagiousness of the disease is doubted, and thus far the opion of the profession tends to the negative.
It has been observed by numerous authors, that persons exposed to all states of the atmosphere, subject to great variations of temperature, of heat, cold, wet and dry - persons traveling a long distance in hot and moist weather, or labouring people are apt to contract the disease. Those that are subjected to the same epidemic influences as give rise to remittent and intermittent fevers, are said to be more susceptable than those that are remote from its cause.
One of the most common reputed causes for its production on the Western shore of Maryland is the imprudence in eating unripe and acid fruits, such as apples, cherries, grapes etc. In eighteen hundred and fifty-three, nearly every family in my district, eight or ten miles around probably suffered from this malady and nine cases in ten the patients had indulged in eating cherries - there being quite an abundant crop that year.
Another and what appears to be more of an exciting than a productive cause is the sitting down upon wet and cold ground, thus armies and travellers, being often necessitated to sleep out with scanty insufficient clothing and food have been attacked by dysentery and thousands have fallen victim to its rage. Again, it exists epidemically without giving the least perceptable cause for its prevalence, and I have known men who were considered scrupulously exact in regard to their diet and habits to be seized with the disease, with as much violence, as those with some reputed cause might be adduced. Then again on the other hand I have known persons who have indulged in every species of luxury, such as eating all kinds of unripe fruits, drinking to excess all kinds of liquors, and exposing themselves to all kinds of harsh and inclement weather, to escape its influence. Drinking of cold water by workmen in warm weather seems to be one of the means by which the distemper is lighted into action; and I have known six out of twelve in the harvest field to be seized, where no other cause could be ascertained, with the exception probably of a little whiskey, which the farmers during those occasions are in the habit of furnishing to labourers.
The eating of indigestible articles of food also seems to be one of the sources by which the disease is set up, but during its prevalence, or where the nature of the malady is epidemic many simple and foolish causes of its production are mentioned, but it appears as often without as with a cause.
The treatment of acute dysentery - In mild cases where the patient only suffers from frequent evacuations, with but little tormina and tenesmus, unattended with fever, and where the contents of the abdomen expelled consists the greater part fecal matter - little or no treatment is required - rest, low diet generally in such cases being sufficient to effect a cure, though we should never rely on this, for very often the mildest cases are prolonged and even prove fatal in consequence of paying too little regard to the state of the patient. Very often when the disease commences with symptoms of diarrhoea it may in many cases be cut short by a simple glass of brandy, or any common astringent, combined with rest and resisting the inclination to stool as much as possible.
But in the more severe forms, where the tormina and tenesmus gain the ascendancy of the will, where the stools are of a mucous purulent and bloody character, where the skin is hot and dry, the tongue coated and associated with these, fever - active medical treatment must be pursued or adopted. If the patient be of a plestoric, robust habit, general bleeding in most instances has a marked tendency to put a stop to, or to decrease the violence of the malady. After this I have observed in those cases that have come under my charge - that small doses of chloride of mercury, combined with opium and ipecacuanha, act very beneficially by calming the irritation, improving the condition of the skin and secretions - together with its antiphlogistic prpoerty - check the inflammation. This is equally applicable in cases after or in the absence of bleeding. It is well in most cases to continue this prescription for twenty four or forty eight hours, giving it at intervals of every four hours, watching its effects, and suspending its employment, when symptoms arise contraindicating its use. The dose in such examples might be given in proportions of proto chlorid. hydrarg. ipecac. of each three to five grains and opium one. Ipecacuanha is said by some to act remedially by lessening the peristaltic motion of the intestines with its revulsive agency.
Another very excellent remedy, after the employment of mercury of in cases where it is not required is the acetas plumbi and opium in equal parts made into pill - one or two or more through the day according to the effects they produce, or as the case may seem to require. To be sure this ought to be the rule and the duty of every prudent physician. It is hard to say what should be the treatment without the case is presented to our view. We always minister to the symptoms and not to the name of the disease, for otherwise gross errors and sad consequences would be the result. There is no agent in the Materia Medica that deserves more praise than the judicious employment of mercury. I have seen well marked cases that have been cured where no other medicine has been used, with the exception of an ounce or two of ol. recini.
Equal to, or next in efficacy is opium. Without this agent our attempts in many cases at cure would be fruitless. We have no other remedy in which there is connected so many important requisites towards the restoration to health in this disease. It seems in every stage to be applicable, and but a few in which it is contraindicated. Yet in those which it appears unfit, it sometimes produces opposite effects - as in cases of hot and dry skin, tongue and fauces, the very effect in the healthy subject it produces, this symptom is very often and frequently entirely relieved by the action of this article.
A very good domestic astringent, which in many parts of the country is very convenient, is made by taking equal parts or quantities of red oak bark, pine tops or branches and ground olive. I have seen this used by persons with the approbation of the physician with the best results, also the common running brier root, made by boiling one or two ounces of the root with a pint of water, which is generally called brier root tea; in order to make it more palatable, it may be slightly sweetened, and the patient may take one, two or three ounces at a time during the day as an ordinary drink.
In the more advanced stage of the disease, where there exists a pretty considerable erethism, anxiety about the praecordia nausea and vomiting, the countenance pale and anemic, the tongue red, the abdomen tumid, distended with flatus and painful to the touch - discharges, foetid, consisting chiefly of blood and mucus.
The best mode of procedure in this instance would be cups or leeches over the abdomen, along the courses of the colon, or inflamation. In the latter stage of dysentery, the best agent known to relieve the distended and tumid abdomen is the oleum Lerebinthinae. This I have seen used often in drachm doses with the greatest satisfaction to the patient and physician.
Opiates internally by way of the mouth, or injection per rectum, demulcent drinks; and when the system is very feeble and prostrated, the diet should be nutritious, and to subserve this purpose, beef tea answers our intention the best.
The action of opium sometimes in this and similar effections varies from its general. It often acts as a purgative secondary by destroying the spasm and irritation consequent upon the inflamation, thus allowing the retained faeces to pass without obstruction, or the opium relieving the strangulation, thus allows the purgatives to act.
We treat all the various forms upon the same general principal - to check inflamation where it is present, to build up the system when the powers of life are declining by nutritious diets and stimulants, to relieve congestion and promote the secretory and excretory functions of the organs, and lastly, but not least, after we have done all to the best of our knowledge to relieve, leave the balance for nature to accomplish.
In the bilious forms we cannot do well without mercury, the liver very often being much deranged in its functions - we will in some cases have to be quite persistent in its use, then again it may be of no utility. In those cases where there is an over secretion and excretion - that is it may not be primarily of any service, but secondarily by correcting the morbid condition in other parts of the body.
In the remittent and intermittent types, Lumia, combined when the patient is aenemic with some of the ferruginous tonics and gentle purgation is all that is necessary to eradicate the disease.
In the chronic stage the best mode of treatment depends upon our attention to diet and regimen - for without this precaution, it is vain to expect a cure. In this stage the patient sooner or later becomes aenemic, thus indicating the replacing properties of the iron, which may be given in doses from a half to a grain of the sulfate two or three times a day. A very good combination of articles to prevent the hemorrhage from the bowels and supply the colouring material in the asthenic and aenemic, consist in Creta. praep., Ferri. Ferrocyan., Ext. haematoxylon, Opii grs.iij, cinna., vj grs., sach alba si, made into eight powders, of which one may be taken every three or four hours. If the case be a bad one, there may be used in conjunction of acetas plumbi grains ten and opium one or two, administered once or twice a day, according to the symptoms and effects.
We may also follow, when the disease is determined and obstinate the acetate of lead and opium pill every two, three, or four hours and if it does not succeed in arresting the symptoms, the nitras argenti pill or sulphate of copper in quantities varying from a half to a grain and a half at the same intervals, and if signs of ulceration come on the two latter named substances may injected per rectum in larger doses.
Prognosis. When the disease is about to end in convalescence, all the symptoms become more mild. The tormina and tenesmus diminishes, the stools become more fecal, larger and less frequent, or there is a general subsidence of all the marks of the disease, and nothing for the most part left, except a moderate diarrhoea, which passes off in the course of a few days. The patient sometimes though not often - after all signs of the disease has gone off - complain of cramps, which come on once or twice a week suddenly, and during their continuance causes great suffering.
But on the contrary, if there should supervene, tympanitis, high fevers with quick and weak pulse, following this, a cold clammy sweat, with coldness of the extremities, the features sunken and depressed, with a purplish hue of the skin, especially about the eyes, mouth and the tips of the fingers - attended with hiccough delerium, subsultus tendinum etc., we conclude that these are omens which portend an unfavorable termination.
Danger in this disease as in all others, is proportionate to the extent of the inflamation. If we ascertain on pressure that the whole of the colon is involved, our attention should be directed with watchful anxiety, and unless means be adopted to check the inflamation and the irritation thus produced - in a large majority of cases the powers of life will sink and the disease end fatally. In Sporadic dysentery - where the patient is well attended to, there is not so much to dread - nearly always yielding to the influence of medical agents and means. But in the epidemic character, we should never be too sanguine for I have known mild cases to occur in young subjects with constitutions strong and robust, and have been in the care of the best physicians, who persued the regular treatment with all its activity, without success.
Anatomical Characters - The lining membrane or the mucous coat of the lower and sometimes of the whole extent of the colon and rectum shows marks of inflamatory action after death. It has been observed where the irritation has been transmitted from the large to the small intestines, the solitary or Brunners glands found in the curvatures of the stomach and duodenum have been found considerably engorged and distended with evident signs of inflamation. There is also a condition existing very much resembling the lesions produced by typhoid fever, the mesentery and the glands of Peyer presenting nearly the same aspect. Ulceration in this disease is more common than any other, except probably that of typhoid fever - the appearance of which presents a smooth surface, or edge coated very often with the membranes that are frequently ejected during the evacuations, such as false membranes, coagulated lymph, etc. There again there have been instances cited where actual mortification and sloughing in the parts have taken place.
Thickening of the coats of the intestines also is produced, and I remember seeing a post mortem examination of a case resulting from this disease in which there was stricture of the colon - the opening so small that the little finger could scarcely be introduced - it was bound down by a thick, firm muscular band.
Various other lesions resulting from a scrupulous taint of the system, stinty diet, depraved nutrition, residing in badly ventilated departments, exposure, etc. have been noticed as producing a dissimilar anatomical lesion. In climates within the trophics the liver is frequently found diseased with hepatic abscesses etc.
In conclusion, let me remark - that in appreciating the moral and scientific lessons and instructions in the art of medicine - delivered by those who have given us practical and theoretical illustrations in the guide of the knife, when it was required, and its utter repugnance when no good could be effected - by those who have taught us practically the true method of searching out disease, and when we have found it, to administer the indicated soothing or healing agent - by those who have marked out the path to the most vital organs, that in case of accident or from a morbid action going on in the system, it may be in our power to apply the ligature or the barrier to death by those who have instructed us in the nature and action physiologically of articles contained in the Materia Medica, as observed by practitioners from their experience in the healing art, and from experiments on the lower order of animal beings, and finally - by those who have acquainted us with the means whereby we can detect fraud and the hypocricy of the assassin when under the cloak of medical agents,
I can only express my sincere thanks, and only hope that the knowledge derived from your wise teachings may prove a credit to the institution in your behalf and my future reward. Wishing that this badly gotten up preamble may meet with your approbation, I respectfully conclude with bright anticipations of being numbered with the profession.
Yours, etc.
Saml. A Mudd
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