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
{778} 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
{779} 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.
Coelius Aurelianus (400 A.D.) adopted the humoralistic doctrine of
Hippocrates and regarded dysentery as an intestinal rheumatism
(catarrh) with ulceration. He seems to have been the first author to
recognize the cardinal fact that dysentery, notwithstanding the number
of its stools, should be classed with the diseases which constipate the
bowels, or, as it {780} was centuries later aptly put by Stoll, "ut
hanc morbis adnumeres alvum potius occludentibus," and he blames
Erasistratus for using nothing but astringents, whereas many cases of
dysentery require laxatives. It is worthy of note that Coelius
Aurelianus ascribes the first use of opium in the treatment of
dysentery to Diocles of Carystus (300 B.C.), who administered the juice
of poppies combined with galls. By the time of Galen opium was so
freely used in the treatment of the fluxes as to call for protest
against its abuse.
Alexander of Tralles (575 A.D.) is often credited as having been the
first to locate the disease in the large intestine. The truth is, he
suggested various rules by which the seat of the disease, whether in
the small or large intestine, might be definitely determined. But none
of these rules--the seat of the pain, for instance, whether above or
below the umbilicus, and the interval of time between the pain and
discharges, whether long or short--possess the least diagnostic value
or add to the attempts in this direction of previous writers--Aretæus,
Archigenes, and Galen. Like these, his predecessors, he recognized an
hepatic dysentery with discharges of bloody serum, which he attributed
with them to atony of the liver, but more boldly than they, and with
characteristic independence, he ventured to treat his patients with
fresh vegetables and fruits, damsons and grapes.
Paul of Ægina (660 A.D.) locates the disease in the rectum, and gives a
graphic account of its symptomatology. He made the mistake of many
later practitioners in regarding as a separate disease a symptom,
tenesmus, which he describes as an irresistible desire of evacuation,
"discharging nothing but some bloody humor, which is the cause of the
whole complaint, being an oedematous inflammation of the rectum which
creates the impression of feces lodged in the intestine and a desire of
evacuation." "Dysentery," he continues, "is an ulceration of the
intestines, sometimes arising from the translation of tenesmus, and
sometimes being of itself the primary affection; and is attended with
evacuations at first bilious and of various colors, then accordingly
bloody, and at last ichorous, like that which runs from dead bodies."
In curious contrast to these accurate observations is the absurd
suggestion of an obsolete therapy (Galen), that the dried dung of dogs
who had eaten bones, when drank in milk which has been curdled by
having heated pebbles put into it, is of great service; but as an
offset to this freak of fantasy is the renewed advocacy of warm milk,
fallen somewhat into disuse since the days of Hippocrates and Galen:
"And milk itself moderately boiled is an excellent thing"--a
recommendation of the milk diet which now plays such an important rôle
in the treatment of so many diseases of the alimentary canal.
Modern.--From this brief survey it is seen that the writers of
antiquity left nothing in the symptomatology of dysentery for
subsequent authors to describe. All further advance in our knowledge of
this, as of all diseases, was now rendered impossible by the extinction
of the light of science in the long night of the Middle Ages, whose
gloom deepens with succeeding centuries and whose shadows fall close up
to our own times.
The modern history of dysentery may be said to begin with Daniel
Sennertus, whose first _Tractatus de Dysenteria_ was published at {781}
Wittenberg in 1626. Sennert gave the deathblow to tenesmus as a
distinct disease, or as even a pathognomonic sign of dysentery, showing
that it is often present in purely local troubles, ulcers, fissures,
hemorrhoids, etc., or is due to disease of other organs--stone in the
bladder, tumors in the womb, etc. He recognized sporadic and epidemic
attacks of the disease, and described under the terms fiens and facta
forms which coarsely correspond to the catarrhal and diphtheritic
varieties of modern pathologists. Improper food, unripe fruits, at
least, cannot be the cause of dysentery, because, he shrewdly observes,
the epidemic of 1624 began in May, before the fruits were ripe, and
ceased in autumn, when they were ripe and in daily use. Moreover,
sucklings at the breast suffered with the disease. Nor could moisture
alone account for the disease, as this epidemic occurred after an
unusually hot and dry spring and early summer. Some other cause must be
invoked, and this other cause is perhaps the occult influence of the
constellations and planets--an explanation which he afterward admits to
be only an asylum of ignorance. In the treatment of the disease the
indication should be to heal the abraded or ulcerated intestine; but
since this cannot be done unless the cause is first removed, "the
abrading, eroding humor should be evacuated and absterged, at the same
time its acrimony mitigated and corrected; then the flux should be
checked by astringents, and the pain, if vehement, lenified and
removed." Purgatives should be repeated until all vicious humors are
discharged.
Sydenham colored his descriptions of the epidemic which he witnessed in
London in 1669-72 with the artistic touches of the master's hand. "The
disease sets in," he says, "with chills and shivers. After these come
the heat of the fever, then gripings of the belly, and lastly stools.
Occasionally there is no fever; in which case the gripes lead the way,
and the purging follows soon after. Great torment of the belly and
sinking of the intestines whenever motions are passed are constant; and
these motions are frequent as well as distressing, the bowels coming
down as they take place. They are always more slimy than stercoraceous,
feces being rarely present, and when present causing but little pain.
With these slimy motions appear streaks of blood, though not always.
Sometimes, indeed, there is no passage of any blood whatever from first
to last. Notwithstanding, provided that the motions be frequent, slimy,
and attended with griping, the disease is a true bloody flux or
dysentery." The efficacy of opium in its treatment causes him to break
out in praises of the great God who has vouchsafed us a remedy of so
much power. But Sydenham was too good a practitioner not to know that
all treatment must be prefaced with laxatives. For "after I had
diligently and maturely weighed in my mind," he says, "the various
symptoms which occur during this disease, I discovered that it was a
fever--a fever, indeed, of a kind of its own--turned inwardly upon the
bowels. By means of this fever the hot and acrid humors contained in
the mass of the blood, and irritating it accordingly, are deposited in
the aforesaid parts through the meseraic arteries." The indications
then were plain--viz. "after revulsion by venesection to draw off the
acrid humors by purging." It was the frequent and successful practice
of Sydenham also to drench the patient with liquids, per os et per
rectum--a mode of treatment which both he and the learned Butler, who
accompanied the {782} English ambassador to Morocco, where dysentery
was always epidemic, hit upon, "neither of us borrowing our practice of
the other." Butler declared that the method of deluging the dysentery
by liquids was the best. But many attacks are cured almost on the
expectant plan alone. This was the case with the excellent and learned
Daniel Coxe, Doctor of Physic, in whom "the gripes and bloody motions
ceased after the fourth clyster. He was kept to his bed, limited to
milk diet; and this was all that was necessary in order to restore him
to perfect health."
Zimmermann (1767) did not believe that improper food could be a cause
of dysentery, as in the epidemic of 1765 fresh grapes were plentifully
supplied to patients and proved an excellent remedy. He also noticed
the muscular pains (rheumatism) which had been mentioned by Sydenham
before him, and the paralyses first noticed by Fabricius in 1720, as
occurring in the course of, or as sequelæ to, the disease. It was only
contagious, he thought, in bad cases, when the stools have a cadaveric
odor. But his main and most useful contributions were in the field of
therapy. He discarded venesection entirely, was among the first to
recognize the value of ipecacuanha, and objected strenuously to opium
until the cause of the evil was expelled. Hence he was vehemently
opposed to all astringents, to the use of which he ascribes the
rheumatisms and dropsies which sometimes occur. Wines and spices were
likewise put under ban; whey he permitted, but not milk, and water
freely, but always warm. Barley-water and cream of tartar were
sufficient food and medicine for ordinary cases, while camphor and
cinchona best sustain the strength in bad cases.
Pringle (1772) observed the frequent occurrence of dysentery
coincidently with malarial fever, and was a firm believer in the
contagion of the disease. He claimed that the foul straw upon which the
soldiers slept became infectious, but maintained that the chief source
of infection were the privies "after they had received the dysenteric
excrements of those who first sicken." It is spread in tents and in
hospitals, and may be carried by bedding and clothing, as in the
plague, small-pox, and measles. Neither food nor drink propagates the
disease, he thinks, for, so far as the fruits are concerned, he too had
seen it prevail before the fruits were ripe. The first cause of the
disease is "a stoppage of the pores, checking the perspiration and
turning inward of the humors upon the bowels." Antimony was his
specific in its treatment. He was also fond of Dover's powder in its
relief, and preferred fomentations to opium, which "only palliates and
augments the cause." The best drink for patients with dysentery was
lime-water (one-third) and milk.
This period of time is made memorable in the history of dysentery, as
of nearly all internal diseases, by the contributions from direct
observation upon the dead body by the father of pathological anatomy,
John Baptist Morgagni (1779). From the days of Hippocrates down, the
seat of the disease had been, as has been shown, pretty accurately
determined, and the same acumen which enabled the clinicians to
localize the affection had inspired them, as we have seen, to define
and describe its nature. But any descriptions from actual post-mortem
examinations were not put upon record until the beginning of the
sixteenth century, when were published the posthumous contributions of
Benivieni (1506-07). In his description of the lesions of the disease
he says that "the viscera displayed {783} internal erosion from which
sanies was continually discharged." Nearly three centuries elapsed
before Morgagni made his anatomical studies--an interval of time void
of any contributions from pathological anatomy; and so little attention
was paid to this branch of medical science that the descriptions of
Morgagni and of his more immediate successors failed to excite any
general interest or make any permanent impression. Morgagni himself,
while he fully recognized their significance, did not consider the
ulcerations of dysentery as absolutely essential to the disease, as
many cases, even fatal ones, did not exhibit them at all. They were not
liable to be mistaken for the lesions of typhoid fever, the ulceration
of Peyer's glands, because, though they may, they only rarely, coexist
in the same subject. As to the membranous fragments sometimes evacuated
with the discharges of dysentery, Morgagni showed that they are
occasionally true fragments or shreds of the intestinal coats, as has
been maintained by the older writers, Tulpius and Laucisius, but are
far more frequently nothing else than inspissated mucus--conceptions
which subsequent studies with the microscope have fully confirmed.
In view of the general disregard of direct observations, it is
therefore not surprising to learn that the nature of the intestinal
lesions gradually fell into oblivion or at least became underrated in
its import. But it is a matter of surprise that Stoll (1780) was able
to declare as the result of autopsies made by himself that, although
the colon is thickened and inflamed, ulcerations in dysenteries are
very rare. This distinguished author did not at all believe in the
contagion of the disease, as he had never seen it attack physicians or
nurses. It developed, he thought with the older writers, as the result
of exposure to cold during a perspiration. He emphatically insisted
upon the frequency of rheumatism as complicating the disease, and
describes in proof a number of cases of painful swollen joints during
and subsequent to the attack. It was his especial merit to have
succeeded in dispensing with the acrid bile as a cause of the disease,
maintaining that hepatic derangements were only accidental
complications, and thus disposed, but only for a time, of bilious
dysentery in so far as it was supposed to depend upon defective or
abnormal action of the liver.
But Annesley (1828) soon reinstated the liver in the pathology of
dysentery, with the exhibition of colored plates displaying abscess of
the liver in connection with the disease, as well as illustrating the
displacements and constrictions of the colon which sometimes occur in
its course.
The fourth decade of our century now brought in the anatomical
contributions of Cruveilhier and Rokitansky, to be followed later by
those of Virchow, upon which the modern morbid anatomy of the disease
is based; while the labors of the Indian physicians and of Copeland,
Parkes, and Vaidy put us in possession of the facts pertaining to its
general pathology. Fayrer has quite recently published the results of
his vast experience with dysentery in India, an important contribution
to the practical study of the disease, and Hirsch has treated
exhaustively of its medical geography. But the merit of publication of
the most complete chapter or work upon dysentery that has ever been
written anywhere belongs to, and is the especial pride of, our own
country. It constitutes the bulk of the second volume of the _Medical
and Surgical History of the War of the Rebellion_. It is a veritable
encyclopædia of knowledge, not {784} only upon the subject of which it
treats, but upon all subjects immediately or even remotely collateral
to it, and is a lasting monument to the labor and the learning of its
author, Joseph J. Woodward, Surgeon of the United States Army.
GENERAL REMARKS.--Dysentery may be a primary or a secondary disease. As
a primary disease it occurs in sporadic, endemic (often closely,
sometimes curiously, circumscribed), or epidemic form, and is either
acute or chronic, according to the nature of its symptoms and lesions.
The ancient types of sthenic and asthenic or adynamic, typhoid,
bilious, and malarial dysenteries belong rather to history than to
modern medicine. The classification of cases in general use at
present--viz. the catarrhal and croupous or diphtheritic forms--has
reference rather exclusively to the nature of the lesion, and is hence
extremely defective. Nor are the divisions (as in cholera) into
sporadic and epidemic forms much more satisfactory, in that they
indicate simply the range or extent of the disease, and by no means
define a separate array of symptoms or lesions; precisely the same
symptoms or lesions being encountered in individual cases of either
form. None of these divisions clearly indicate differences in etiology,
upon which factor alone can any acceptable division of cases be based.
Perhaps less objection may be urged against the assumption of catarrhal
and specific forms, including under the provisional term catarrhal all
the cases which cannot as yet be accounted for by the action of a
special or specific cause.