At times, however, the lymphocytes may be the leucocytes showing the greatest relative increase.
Collapse Types.—In the most severe types of dysentery we may have an abrupt onset with rigors and vomiting and a high fever. This fever gives way to a subnormal temperature and the patient shows signs of collapse and such a case may die without having passed dysenteric stools. The abdomen is rigid and very tender on palpation.
Entero-dysentery.—In those cases where the process extends to the lower portion of the small intestine the general symptoms are much more severe although the tenesmus is less and the stools less frequent and more voluminous. They contain much blood and mucus mixed with feculent material. Shiga calls such cases entero-dysentery.
In severe cases of the more typical dysentery or colodysentery, as designated by Shiga, the stools may change from the mucopurulent mass to a serous discharge which is very rich in albumin and of an albuminous odor. In such cases emaciation of the patient is very rapid. Such cases may show signs of collapse with cold clammy skin and the clinical picture one associates with cholera.
It has been suggested that such cases may be due to action of the dysentery toxins on the adrenal.
This serous fluid may contain the flesh-like particles which the French liken to gut scrapings. During convalescence there may be an arthritis, which however does not impair the function of the joint.
Complications.—In addition to the arthritis there may be neuritis, which, in severe cases, may go on to muscular atrophy. In the arthritis the knee joint is that most frequently involved. This complication appears late in the course of the attack. Arthritis may be frequent in one epidemic and absent in another. The joint swelling usually clears up completely. Some of the reported joint involvements are undoubtedly serum reactions from antidysenteric serum treatment. Rarely in Shiga infections we may have an irido-cyclitis. Subnormal temperature may follow severe attacks.
In some epidemics of dysentery gangrenous manifestations have been common. This is a very fatal type and is recognized by the passage of dark-brown serous discharges containing ashy gray to black sloughs or even tubules of gangrenous mucosa, the stool having a putrid odor. The general symptoms are pronounced, there being a dry glazed tongue, and low muttering delirium with a thready pulse. It is the typhoid state.
It is usual to consider bacillary dysentery as a self-limited disease, running on to convalescence within ten days or two weeks.