THE
Southern Medical Record.
A MONTHLY JOURNAL OF PRACTICAL MEDICINE.
Communications must be addressed to R. C. Word, M. D., Managing Editor.
" Quicquid Prcecipies Esto Brevis."
Vol. XVII. ATLANTA, GA., MARCH, 1887. No. 3.
ORIGINAL AND SELECTED ARTICLES.
EPIDEMIC DYSENTERY.
By J. E. Wright, M. D., Columbia, La.
I propose to furnish you a brief account of an epidemic of malig-
nant dysentery which prevailed in Caldwell and contiguous par-
ishes, in the Summer of 1885. The scourge began the last week
in May ; assumed epidemic proportions very soon ; culminated
about the middle of July, and then began slowly to decline, both
as to the number of cases and virulence of type. Fatal cases, how-
ever, occurred as late as the last of September and beginning of Oc-
tober. For deadly virulence and malignity of type it has, probably,
had few paralells in modern times, especially amongst a rural
population.
Few diseases, perhaps, known to our systems of nosological clas-
sification have attracted more attention, or had more able expo-
nents than dysentery.
In the ordinary, as well as the purest classical descriptions, of
this disease, the same name, with appropriate modifications, is used
in all languages. Its classical history extends far back into remote
antiquity. Nearly five thousand years before the Christian era,
Heroditus tells of its terrible devastation of the great army of Xer-
xes in the plains of Thessaly ; Galen, A. D. 164, the great exposi-
tor of ancient medicine, has left on record a graphic description of
the disease. So true is this, that the literature of the subject for
many centuries after his time was little more than a paraphrase or
amplification of his text. In more recent times, the semeiographv
of the disease has been so often and so ably treated by the great
master minds of the profession that to dwell on that topic would
be superfulous reiteration. The epidemic about to be described,
however, had some distinctive features, so peculiar as to require
special notice. The prodromic stage was short; the transition from
perfect health to severe illness was often sudden. Nausea and vom-
iting often ushered in the attack ; the vomited matter was usually
dark green—sometimes almost black—thick and ropy in consist-
ence, and very offensive in odor ; uneasy sensations in the bowels ;
borborygmus eructations of gas, etc.; thirst and complete anorexia
marked the inception of most cases. The alvine dejecta were diar-
rhceal in character at first, but soon became sero-sanguinolent.
These, in turn, were soon succeeded by the mucous, blood, pus,
shreds of pseudo-membranous matter, necrosed mucous tissue, etc.,
variously proportioned and commingled, and so characteristic of
the disease in question as to be regarded by all observers ^pathog-
nomonic. At a still more advanced period of the disease the lotuta
carnea or fleshy stools, regarded since the time of Hippocrates as
ominous of great danger, if not positively mortal, were occasionally
seen. I cannot now recall to memory a single case in which these
carneous stools appeared which recovered. One of the most notice-
able of the objective features of this epidemic was the revolting
odor of the dejecta. It was so pregnant, so all-pervading, and so
unutterably disgusting as to defy description, yet never to be forgot-
ten when once recognized. Tormina and tenesmus, usually so pro-
nounced and troublesome in sporadic dysentery,'were conspicuous
only by their almost entire absence in this epidemic. The great
and peculiarly distinctive feature of the scourge, however, was the
adynamia—the utter prostration—which attended its very incep-
tion. From its first onslaught the aspect of the patient was sug-
gestive of the most profound prostration of the physical energies-
The countenance was pinched, shrunken, Hippocratic, ashy-pale,
and cadaverous ; -the finger tip, pressed upon the surface and mov-
ed firmly on a line for an inch or two, leaves a blanched or white
mark behind it, which very slowly regains the hue of the contigu-
ous integument—thus distinctly suggesting the sluggishness, stag-
nation and almost complete stasis of the capillary circulation. A
large superficial vein, being pressed upon so as to arrest the blood
current, very slowly refills after the pressure is removed ; the lips,
tongue, buccal cavity, pharynx, etc., were leaden or livid in hue,
and suggestive of cyanosis; the radical artery, a scarcely distinguish-
able thread, was obliterated by slight pressure ; the pulse was usu-
ally accelated in frequency—often being 120 to 130 to the minute,
and irregular in rhythm ; temperature but slightly elevated—often
normal or sub-normal. This want of correlation between pulse
and temperature was a marked feature throughout the entire course
of the disease. The tongue was dry, contracted, and more or less
coated with dark, foul-looking saburra, and cool or cold to the
touch. The healthy hand laid flat on a patient's body received the
sensation caused by the touch of a cold-blooded reptile ; the gang-
lionic centres of the nerves of organic life seemed to be paralyzed ;
the functions of the vaso-motor and thermic centres were in almost
complete abeyance, and the great central organ of the circulation
profoundly embarrassed ; the respiratory movements were gener-
ally accelerated, and frequently interrupted by deep sighing ; rest-
lessness, jactitation, insatiable thirst, and unspeakable disgust at
the very thought of food were attendant in most cases throughout
the entire course of the disease. Toward the close of some fatal
cases complete paralysis of the sphincter ani muscle occurred, and
the anal opening was sufficiently patulous to see the interior of the
rectum several inches above the outlet. No case recovered in
which this symptom occurred.
The experienced clinician who reads this array of symptoms will
■find obvious reasons for the appalling rate of mortality which at-
tended the dreadful scourge. For the first three or four weeks the
-death-rate far exceeded that of the epidemic cholera, which was
prevailing in Spain, France, and Italy at the time. I kept no mor-
tuary record, but think it a moderate estimate to say that, of all at-
tacked during the rise and culmination of the epidemic, at least 80
per cent. died. After the fury of its onslaught was somewhat
abated, the mortuary rate fell to about 40 percent. Even a curso-
ry reference to topographical, meteorological and climatic influen-
ces, as pathogenic factors, would cover more space than I could
hope to occupy. Much might be said, under each of these heads,
-of great interest and importance. I must confine my remarks, how-
ever, to the noteworthy fact, that frequent thunder, vivid flashes
-of lightning, and heavy rainfalls occurred during the fiercest prev-
alence of the epidemic. When not cloudy, the solar heat was in-
tense, and though the nights were comparatively pleasant, the mer-
cury rose each day to 96°, 98° and even ioo° in the best protected
places. The much hackneyed malaria—so convenient a mask for
ignorance and empiricism—is pandemic, and well-nigh ubiquitous
in this valley and neighboring hill-country ; yet its role in this ep-
idemic was so inconspicuous as to be scarcely recognizable.
We are able to say but little under the head of Etiology, what-
ever the predisposing cause or causes ; there can be no reasonable-
doubt that a specific poison of most deadly virulence caused the sud-
den and simultaneous prostration of such large numbers. No age,,
nor sex, nor race, nor social position afforded the least immunity.
The infant at the breast, the octogenarian, and all the intermediate
ages, were alike invaded. The inmates of' the hovel, with its
squalid poverty ; the occupants of the mansion, with their abun-
dance, and all classes between these extremes, were attacked with-
out discrimination. The negroes appeared to suffer a higher rate •
of mortality ; but this was probably owing to the impossibility of
their obtaining medical attendance. The physical effect of the
scourge was appalling—some fleeing in undisguised terror, and
others so demoralized by panic as to be almost incapable of ren-
dering assistance in nursing the sick. The physicians, taxed tQ the-
utmosl limit of endurance, both physically and: mentally, with rare
and unimportant exceptions, stood heroically in solid phalanx at
the post of duty, and fought this new and terrible disease, in the
very teeth of defeat and death, to the bitter end with self-sacrific-
ing devotion to their noble calling and the cause of suffering hu-
manity, whilst Death held high carnival around them, and all their
struggles seemed destined to defeat; with a courage and intrepid-
ity equal to that which prompts the soldier to face a blazing bat-
tery on the field of carnage, they never once quailed or swerved a
hair's breadth from the direct line of duty. This passing tribute
to professional merit may seem irrelevant in this connection, but
those on whom it is bestowed most nobly earned it.
Is? it catching ? Is it contagious ? were questions often pro-
pounded. I always and unhesitatingly replied, Yes ! and I believe
my confreres, without a dissenting voice, agreed with me. The
specific disease germ—the toxic agent—the materies morbi, be it
bacteria, micrococci or spores ; be it a living active organism or a
gaseous imponderable virus, too subtle for the lens of the micro-
scopist or the reagents of the laboratory ; be it, in fine, what it may,,
is as much a specific virus as is that which produces small-pox,,
measles, scarlatina or any of the exanthemata. Whilst we are not
prepared to maintain that this epidemic of dysentery was contagi-
ous in the same sense and to the same extent as the exanthematic
diseases above named, we do contend that it was communicable-
from the sick to the well by more or less prolonged contact; by
inhaling the effluvia from the body, breath or bed of a patient, and;:
especially from the alvine dejecta.
From close observation of the clinical history of this scourge, andx
from facts collected during its prevalence, we believe its contagions
-depended upon-a specific poison, or toxemia, wholly independent
of idio-miasmata or cro-wd poison, so strongly emphasized as a fer-
tile source of propagation by the learned and highly distinguished
Dr. Joseph J. Woodward, of the U. S. Army, in his classical work
-on the Medical and Surgical History of the War. Did time and
space permit, we could bring an array of facts in support of our
views on this point, which, we think, would be conclusive and ir-
refutable ; but even a cursory reference to the data we possess on
this subject would lead us quite beyond reasonable limits, and (how-
ever regretfully) we must forego the task.
Having thus briefly and roughly sketched the outlines of this
epidemic, we may conclude with a brief reference to the important
subject of
TREATMENT.
The usual dose of salts and laudanum or paregoric, by which
the treatment is begun, was found, after repeated trials, to be a
failure in its effects, and was abandoned ; hypodermic injections
of morphia sulph., to grain, supplemented by large cataplasms
of mustard to stomach and bowels, and repeated as occasion re-
quired, afforded relief to the nausea and vomiting, and thus added
to the comfort of the sufferer; irrigation of the rectum and colon
with large enemata of hot water, carried by a gum catheter attached
to a Davidson syringe above the sigmoid flexure and pumped into
the bowels very slowly, in large quantity, at intervals of two, four
or six hours, afforded great comfort, and in many ways was thought
salutary. It was soothing to the hyperasmic and hyperaesthetic
.mucosa, and possesses, when thus intelligently applied haemostatic,
antiseptic and calminative properties of great value. By removing
the semi-putrescent debris, consequent upon the morbid condition
of the parts, it is reasonable to conclude that not only a fruitful
source of irritation is got rid of, but a probable source of auto-in-
fection also ; hence I cannot insist too strongly on copious and fre-
quently repeated irrigation, as one of the most valuable remedial
measures at our command in the treatment of all severe types of
dysentery. It possesses the additional advantage of being abso-
lutely harmless, when properly used, and is often a source of un-
speakable comfort to the sufferer. Although at variance with very
high authority, I must insist on hot water—as hot as can be borne—
in preference to cold, iced or tepid, and this preference has been
determined by repeated clinical observations of the effects produced
by enemata at different temperatures. After thorough irrigation,
Tthe water having passed off, it was my custom to introduce a sup-
pository of solid opium, made soft by glycerine or water, high
above the sphincter, and retain it there, if necessary, for an hour
or more by a suitable compress pressed firmly by careful hands-
against the parts; The quantity of opium thus used varied, from B'
to 8 or io grains, according to age and other peculiarities of the
patient. The prostration, and tendency to cardiac failure, required
an early resort to measures of support; brandy, whisky, milk punch,,
egg-nogg, meat juices, hypodermics of fluid extract digitalis, etc.,
were the means employed for this purpose, and which appeared
to do most good.
Heroic doses of calomel, advocated by some, were found to be
useless, if not pernicious. Small alterative doses of mercury (sub.
mur.) in fractions of a grain, repeated every four to six hours, seem-
ed to do good in some eases, by moistening the tongue, and other
evidences of emulging the secretions ; but its warmest advocates
could claim no marked curative effects for mercury administered-
either tentatively or heroically. This fact, added to popular pre-
judice, caused it to be abandoned. Ipecacuanha, in doses of 20 to
40 grains, well mixed with fl. 3 i or ij of syrup of orange, always
did good service, and no doubt was the means of saving some
lives. The writer administered it in the .following manner : Thirty
minutes or more before giving the drug, the abdomen, from ensi-
form cartilage, was covered with a mustard cataplasm wide enough
to embrace the entire surface, and 20 to 30 gtts. tincture opii given.
When the pungency of the mustard can be endured no longer, it
is removed, and the bolus of ipecac washed down with a single
swallow of water. The patient is required to lie flat on his back, s
not move or speak if possible to avoid it, and to swallow absolutely
nothing, for three hours. Any time during these three hours, if
restlessness and complaint are at all troublesome a hypodermic of
i to £ grain of morphia is administered. This will generally re-
store quiet, and prevent premature vomiting. Three hours after the
ipecac, small pellets of ice may be swallowed, and a few spoonfulls-
of boiled milk may be given occasionally. If prostration «s much
increased by the relaxation, nausea, etc., caused by the ipecac,,
milk punch, toddy, and, if deemed necessary, hypodermics of
whisky, brandy, ether, etc., may be used to support the circulation.
The first dose of ipecac rarely fails to produce feculent stools, with
less blood and mucous, free diaphoresis, and great amelioration of
all the symptoms. In ten to twelve hours this course may be re-
peated, the dose of ipecac being a little smaller. The ipecac being
slightly diminished in quantity, may be thus repeated at intervals-
of ten or twelve hours until three or four doses are used^giving
supporting fluids cautiously in the intervals between the doses. If'
no marked good impression is made by this drug, thus used, in
forty-eight hours it should be abandoned. The faithful use of irri-
gation, as above indicated, and the ipecac treatment fairly tried,
and each having failed (and fail they did In many cases), the im-
'portant question presents itself, What next ? I answer, unhesita-
tingly, Opium—Brandy ! The remarkable insusceptibility of the
system to the physiological effecis of opium was a distinctly mark-
ed feature of this epidemic. This insusceptibility we regard as an
indication to push the drug, regardless of quantity until its physi-
ological effects are produced.
To'illustrate, I will briefly refer to a case : A gentleman, fifty
years old, presenting a typical case, had had saline purgatives,
thorough irrigation with copious hot water'enemata, frequently re-
peated ; had a 40-grain dose of ipecac ten hours subsequently, a
30-grain dose, and twelve hours thereafter another dose of 20 grs.
The dysenteric symptoms were but slightly ameliorated, and the
subjective symptoms forbade the further use of ipecac. A suppos-
itory of 10 grains of solid opium, properly softened, was passed
high up into the rectum and retained by compress to nates ; 2 grs.
opii in pill form were administered per ovem every two hours for
twenty-four hours, the suppository of 10 grains being repeated ev-
ery twelve hours, and a hypodermic of grain sul. morphia used
six hours after each suppository. Thus, he took 24 grains of solid
opium of excellent quality per ovem, 30 grains by suppository, and
grains of sulpli. morphine hypodeimically, within twenty-four
hours' The suppositories were retained and presumably absorbed,
and no emesis having occurred, the 24 grains taken into the stom-
ach were also presumably appropriated ; and yet this man, perfectly
free from all suspicion of opium-habit, had not the slightest symp-
tom of narcotism or any other unpleasant symptom which could
be attributed to opium. It is proper to state that whilst this heroic
plan was being pursued, the patient was constantly watched with
the view of detecting the first indications of opium-poisoning, but
none appeared, not even marked contraction of pupils. The pa-
tient being greatly prostrated, with distinct tendency to cardiac
failure, had the opium treatment supplemented vigorously with
egg-nogg, milk punch, and hypodermics of fluid extract of digitalis.
The opium treatment was continued in gradually diminished doses-
at progressively increasing intervals, with brandy and other sup-
ports, for several days, when he slowly emerged from the very
jaws of death and entered upon a tedious but perfect convalescence.
During all this time no symptom of opium narcosis, at any time,
appeared.
A few years previous to this epidemic the writer had occasion
to treat several cases of sporadic dysentery in this same family, and
the lady—wife of case just stated—acquired great confidence in,
and partiality for, a mixture then used by me, under the name of
" Creasote Mixture," composed ot 4 grains sulph. morphine, 32
gtts. creasote, and 4 ounces of camphor water, and directed in tea-
spoonful (5 i) doses after each disturbance of the bowels, etc.
Immediately after this epidemic began she requested me to pre-
pare for her half a pint (^8) of the mixture, which I did. When
it was delivered to her, three or four of the family were prostrated
with, and under treatment for, flux. The lady, after losing several
night's sleep and suffering great anxiety and alarm, was seized
early one morning with the symptoms of the disease in a violent
form ; she went to her bottle of creasote mixture and, in the pres-
ence of a grown daughter, poured out and drank over half a tea-
cupful (about 3 ounces), or 3 grains of morphine, 24 drops of crea-
sote, and 3 ounces of camphor water ! Previously she had vomi-
ted and was much disturbed with her bowels. Within an hour af-
ter swallowing the draught she was found asleep in a back room
by some of the family ; nothing was said to the physicians about
what she had done. In the confusion and anxiety incident to the
care of several other bad cases in the house, she was forgotten and
no atten paid her for several hours, when she was found fast asleep
and sweatina profusely. As respiration was free from stertor, reg-
ular and no.t very much slowei' than normal, no means seemed nec-
essary to combat the effects of the morphia, and she was let alone.
She continued to sleep for twelve hours ;■ sweated profusely, and
awoke feeling hungry. All symptoms of dysentery were gone, and
she passed through the epidemic of several weeks' duration, ex-
posed day and night to .the effluvia from the bodies of the sick, dy-
ing and dead, losing sleep and suffering inexpressible distress and
anxiety of mind, without having any symptom of the prevailing
scourge afterward.
It would be easy to add many cases illustrative of the extraordi-
nary tolerance of opium in this epidemic, but the above will suf-
fice. An almost equal insusceptibility to the effects of alcoholic
stimulants was manifest. The poison seemed to act with special
virulence on the nerve centres of organic life. The cerebro-spinal
system was much less affected, the intellectual faculties remaining
intact to the last.
I am conscious of having done nothing more than outline the
treatment of this scourge, in what has preceded. It may be briefly
summarized in saying that ipecacuanha, opium and its prepara-
•tions, faithful and frequent irrigation of the bowels with copious
hot water enemata, brandy or whisky, milk and meat juices or
broths, good nursing, cleanliness, and the assiduous use of deodo-
rants and disinfectants—all used with intelligent discrimination—
afforded the best results. All the systems of medicine known in
civilized Christendom were brought into use by their various vo-
taries, and all alike most signally failed. Many cases were mori-
bund in a few hours after attack, and no case recovered without
the best of care.

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