Amcebic dysentery has so rarely been described in children that the diagnosis is probably never entertained by the practitioner. 'Within a short space of time five cases were identified and suc cessfully treated by the author at the Johns Hopkins Hospital. The patients ranged in age from 2 to 5 years, and illustrated a moderately severe type of the disease, with the exception of one child who was very seriously sick. The clinical picture in these cases was very indefinite. The appetite and gen eral health were good, fever and fle celeration of the pulse were hardly notice able, and the blood-examination showed only a very moderate ancemia of the sec ondary type. Stools varied from two to six in twenty-four hours, were rarely associated with pain, and presented nothing,, characteristic to the eye. They were of every degree of consistence, and might, or might not, show admixture of blood. The odor was always most offen sive. Microscopically, three very typical structures are to be found, namely: live aniceba containing red blood-cells, Chareot-Leyden crystals, and numerous eosinophile cells. The presence of either of the latter elements should make tbe observer extremely suspicious of amcebic dysentery, as they occur in no other condition except helminthiasis, which can easily be excluded. The presence of the amceba is, of course, final. S. Am berg (Dull. Johns Hopkins Hosp., Dec., 1901).
(B) Diphtheritic Dysentery.—The pri mary variety presents somewhat differ ent symptoms, depending upon the stage —whether acute or chronic—of the dis. ease. In the acute stage the symptoms often from the outset are severe. There may be high fever, great prostration, ab dominal pain, and frequent discharges, with tormina and tenesmus. The grip ing pain and straining are the chief sources of sufferincr. Delirium may set in early, and the clinical features resem ble severe typhoid. Osler states that he has known this mistake to be made on more than one occasion. The pulse, in the majority of cases, is but little, and sometimes not at all, accelerated. Fever, except in the severe cases, is not a prom inent feature. Flint states that great frequency of the pulse denotes gravity and danger, but that the converse does not always hold good. The discharges are frequent and diarrhceal in character; blood and mucus may be found early, and sloughs may make their appearance. The presence of pseudomembranes and of necrotic portions of the intestinal coats is characteristic of the diphtheritic form of inflammation. The other in gredients are common to both the ca tarrhal and the diphtheritic varieties of inflammation. Upon microscopical ex amination the cellular elements are found to be relatively few in numbers, those most constantly present being. cylindrical epithelial cells, showing more or less fatty degeneration. Red blood corpuscles and leucocytes are observed, especially- where much blood and mucus are admixed, and large numbers of leucocytes in the purulent discharges. Fibrin also occurs, and bacteria appear in great numbers. When improvement begins feculent matter appear in the stools. The duration of the disease from the (late of attack to convalescence varies from four to twenty-one days. When death takes place it usually re sults from asthenia. The pulse becomes weaker and accelerated, the tongue dry, the face pinched, the skin cool and cov ered with sweat, and the patient sinks into a drowsy condition. Consciousness
may be retained until the end.
(C) Chronic condi tion usually succeeds an acute attack. Clinically the chronic forms of diph theritic are not sharply marked off from those of amcebic dysentery. The latter disease may be subacute from the outset and fail to present an acute period. The lesions in the intestine will depend upon the origin: if amcehic, then ulceration with little tendency' to healing is the rule; if diphtheritic, then pigmented cicatrices or these together with imper fectly-healed ulcers are met with. The intestinal walls are thickened and the sigmoid flexure may be palpated as a hard, resistant tube. The disease pre sents protean symptoms and cannot always be sharply separated from chronic diarrhcea. Its course may extend over months and even years. Many of the characteristics of the acute disease are wanting. The composition of the stools is variable; blood, necrotic tissue, and pseudomembranes are rarely found. There are periods of improvement and exacerbation; the patient loses weight and strength, becomes emaciated, suf fers from periods of psychical dcpres sion, and may become bedridden. The degree of emaciation may be extreme, and a severe secondary amemia some times develops. The evacuations— which vary from five to twelve or more in the twenty-four hours--take place usually without tenesmus, and with only slight colicky pains. They are fluid, of greenish-yellow or brownish-black color, now and then admixed with blood and mucus. Sometimes the stools are puru lent. Indiscretions in diet are followed by' an increase in the colicky' pains.
(D) Anuxbic symp toms presented are very variable. What characterizes the disease are au "irregu lar course marked by periods of inter mission and of exacerbation of the diar rhcca, a tendency to chronicity, and the frequent occurrence of abscess of the liver" (Lafleur). For clinical purposes Lafleur groups the cases under (a) g,rave or gangrenous forms; (b) dysentery of moderate intensity (showing periods of intermission and of exacerbation); (c) chronic forms. Kartulis recognizes ca tarrhal and ulcerative stages in the diseases. The catarrhal stage, in contra distinction to epidemic dysentery, is relatively of infrequent occurrence. This stage tends to pass into the more severe or ulcerative form. In the ca tarrhal stage the dejections are yellow, bile-stained, and of mushy or fluid con sistence. When the stools are small, then mucus, which may be blood-stained, appears. As the intensity of the symp toms increases chunps of mucus and blood are more abundant; still later the stools present a beef-water appearance, in which clear clumps, resembling frog spawn, — altered starch-grains, — float. With the advance of the ulceration they become more copious, watery, and less homogeneous; there is less blood and a great deal of shredcly material appears admixed with the mucus. Fragments of necrotic tissue from the bases of the ulcers,—small, grayish-yellow masses,— which always contain amcebm, are pres ent. When there is great and rapid sloughing, then the stools are greenish, grayish, or reddish brown and are still more variegated in appearance. In con sistence they are watery or pultaceous and in odor penetrating and highly offensive. In the chronic form the stools are homogeneous, watery, or gruel-like; they contain few or many flakes of clear mucus, but seldom any blood or necrotic fragments of tissue.