A system of practical medicine. By American authors. Vol. 2

by Unknown

HISTORY.—Ancient.—In its clinical history dysentery is one of the oldest known diseases, the name being found in common use before the time of Hippocrates, as in the often-quoted passage from Herodotus (443 B.C.), who relates that it and the plague reduced the army of Xerxes on the desert plains of Thessaly.

Fayrer informs us that in the ancient system of Hindoo medicine of the Ayur Veda, and in the commentaries of Dhanwantari, Charaka, and Sussutra, which carry us back nearly three thousand years, and in later Sanskrit writers, dysentery is described by the name of atisar, under two forms—amapake, or acute, and pakistar, or chronic; these again are subdivided into six varieties, ascribed by those ancient sages to changes in air, bile, phlegm, food, or to perturbations of the emotions and passions.

Hippocrates (430 B.C.) makes frequent reference to the disease, the nature of which he regards as a descent of the humors from the brain. "Men of a phlegmatic temperament are liable to have dysenteries," he says, "and women also, from the humidity of their bodies, the phlegm descending downward from the brain."

"The disease is caused," he says more exactly in another place, "by the overflow of phlegm and bile to the veins of the belly, producing ulceration and erosion of the intestine." In his country, at least, it seemed most to prevail in spring, but it was clearly connected with the heat and moisture of this season in Greece—prime factors everywhere in the genesis of the disease: "For when suffocating heat sets in all of a sudden while the earth is moistened by the vernal showers and by the south wind, the heat is necessarily doubled from the earth, which is thus soaked by the rain and heated by a burning sun, while at the same time men's bellies are not in an orderly state, nor is the brain properly dried." Of the prognosis he observes with great acumen, "Dysenteries when they set in with fever ... or with inflammation of the liver and hypochondrium or of the stomach, ... all these are bad. But such dysenteries as are of a beneficial nature and are attended with blood and scrapings of the bowels cease on the seventh or thirtieth day, or within that period. In such cases even a pregnant woman may recover and not suffer abortion;" whereas, "dysentery if it commence with black bile is mortal." Galen comments upon this statement that such a discharge is as incurable as cancer. The practitioner of our day will interpret this assertion, which was repeated with singular unanimity by all the writers of antiquity, with the belief that the black bile was blood, and that such cases really were cancers. Indeed, Paulus Ægineta distinctly says, "Dysentery arising from black bile is necessarily fatal, as indicating an ulcerated cancer."

Thus, although dysentery is among the oldest of the known maladies, and was recognized then as now by the same symptoms, the disease was by no means closely defined or differentiated in ancient times. As Ackermann long ago pointed out, many other affections were included under the term dysentery, and some of the symptoms of true dysentery, notably the tenesmus, were raised to the dignity of distinct diseases.

The gravity of the so-called lotura carnea, the fleshy stools, was fully appreciated by Hippocrates, as is evidenced by the remark that "if in a person ill of dysentery substances resembling flesh be discharged from the bowels, it is a mortal symptom." Fleshy masses, [Greek: xysmata], scrapings of the guts (originally epidermic exfoliations from the bodies of gladiators, used in pills as a tonic), were frequently alluded to by the older writers, more especially by Aretæus, in description of the discharges of dysentery. Hippocrates was also aware of the fact that dysentery may be a secondary as well as a primary malady. "One may expect," he says in speaking of the victims of gangrene, "that such patients will be attacked with dysentery; for dysentery usually supervenes in cases of mortification and of hemorrhage from wounds." Finally, Hippocrates recognized the effects of emesis in relief of the disease with the remark in one of his aphorisms that a spontaneous vomiting cures dysentery.

Celsus (25 B.C.-45 A.D.), the great encyclopædist, whose works "constitute the greatest literary monument since the days of Hippocrates," compiles all the information obtained up to his time; but it is plain as regards dysentery, though he defines it in terms that might stand in a modern text-book, that he has nothing new to add to the knowledge of the Hippocratic school. He named the disease from one of its most prominent symptoms, tormina (tenesmus he considered a separate affection), speaks of the stools as being mixed with mucus and fleshy masses, and in its treatment especially enjoins rest, "as all motion proves injurious to the ulcer."

Aretæus (50 A.D.), of all the authors of antiquity, wrote the most perfect and at the same time the most picturesque account of the morbid anatomy and symptomatology of this disease. The gross appearance of the ulcers in the intestine and the common character of the discharges he describes with the accuracy of the modern pathologist and the ardor of the true clinician. He speaks of the superficial, the deep-seated, the irritable, and the callous ulcer. There is, he says, "another larger species of ulcers, with thick edges, rough, unequal, callous, as we would call a knot of wood; these are difficult to cure, for they do not readily cicatrize, and the cicatrices are easily dissolved." Their tendency to arrest and renewal and their general and local effects he notices at length. "There may be a postponement of their spreading for a long time," he says, "various changes taking place in the ulcers, some subsiding and others swelling up like waves in the sea. Such is the course of the ulcers; but if nature stand out and the physician co-operate, the spreading may indeed be stopped, and a fatal termination is not apprehended, but the intestines remain hard and callous, and the recovery of such cases is protracted." Vivid descriptions he gives of the stools: "Sometimes they are like chopped tallow, sometimes merely mucus, prurient, small, round, pungent, causing frequent dejections and a desire not without a pleasurable sensation, but with very scanty evacuations." Again, they are "fetid like a mortification;" composed of "food now undigested, as if only masticated by voracious teeth, ... the dejection being discharged with much flatulence and noise; it has the appearance of being larger than its actual amount."

Galen (164 A.D.) attempted to correct the pathology of his contemporaries, who considered all bloody discharges dysenteric. There are four distinct varieties of bloody stools, he claims, only one of which, that due to ulceration of the intestine, deserves to be called dysentery. The bilious stool he derived from melancholy, and the fleshy stool from disease of the liver. But, though Galen regarded the presence of blood as a necessity, he was well aware of the fact that the stools contained ingredients other than blood. It was Galen who first used the word scybala ([Greek: schybala], feces) to express the small, solid masses of excrementitious matter often voided with the stools. In his treatment of the disease he made much use of the various drying earths, the Samian, Lemnian, Armenian, the sources of which he made long journeys to visit in order to become better acquainted with their properties, and which are better substituted in our day by bismuth, chalk, magnesia, and the carbonate of iron. It is the distinguished merit of Galen to have called special attention to the anatomical seat of the disease. Ulceration of the intestine he claimed as the very essence of the disease, and all the physicians of his day, he maintained, regarded as dysenteric only such cases as are attended with ulceration.

Galen was the exponent of the flower of Grecian, we might say of ancient, medicine. With very few exceptions, the later writers, if they do not obscure the original text with their speculations, are content to simply paraphrase the observations of their predecessors, and the subsequent contributions to the ancient history of dysentery may be briefly summed up in a few additional notes.