Part 116

As the diarrhoea of Bright's disease is salutary, no effort should be made to arrest it. Its periodical recurrence prolongs life. In tuberculosis the special character of the diarrhoea must be considered, and every effort must be made to control it. In the eruptive fevers an early diarrhoea, as in scarlet fever, does harm; it delays or prevents the normal development of the eruption. In the later stages it is of service sometimes, as in measles, when it leads to a rapid fall of temperature. The course of action depends upon the nature of the specific disease and upon the time of the appearance of diarrhoea.

There are certain principles, founded on the knowledge derived from pathological study and from the experience of the past in the treatment {690} of intestinal catarrh, which guide us to a treatment which is more or less rational in all cases.

Rest is essential to the cure of the inflamed intestine, but absolute inertia of the bowel is undesirable, even injurious. The retention of fluids, transuded serum, bile, intestinal juices, and partly-altered food is hurtful. Decomposition sets in and gas is developed, which by distending the bowel causes great suffering and increases the inflammation. The movements of the intestine are not entirely under control; the patient must be fed; digestion and assimilation involve the activity of inflamed parts. The stomach can be made to do most of the work, but the sympathy of action is so close between the stomach and intestines that one cannot function without the other being excited into activity.

The first rule of treatment is to put the patient to bed and to keep him in a horizontal position. Even in mild cases time will be saved by resorting to absolute rest at once. If the attack is at all severe, the bed-pan should be used; the effort to rise and the straining at stool exaggerate peristaltic movement, increasing the frequency of the evacuations. Additional rest can be given to the intestines by applying a flannel binder around the trunk, compressing the abdomen; broad strips of adhesive plaster could be used for the same purpose. In cases where the diarrhoea, tympanites, and griping pain are not relieved by other measures this suggestion may be of service.

In order to lessen intestinal hyperæmia and allay suffering, counter-irritants and soothing external applications are employed. Local blood-letting, although in vogue during more than two centuries, has fallen into disuse. Recent authors still continue to advise the application of leeches to the anus in order to deplete the portal circulation, but it is a decided objection to this remedy that the fluid stools irritate the leech-bites and cause much discomfort. Sinapisms or turpentine stupes may be of some service apart from the relief which they give to pain. Blisters might be more generally used than they are when the tenderness on pressure is confined to the colon. In intense inflammation they should always be tried. Hot poultices of flaxseed meal or hot fomentations of any sort applied over the entire abdomen have a soothing and beneficial effect. A flannel compress saturated with alcohol and covered with gutta-percha cloth makes a most agreeable application.

The directions for diet should be carefully and explicitly given. In the onset of the attack entire deprivation of all food for twenty-four or forty-eight hours is expedient. To relieve thirst, cracked ice, carbonic-acid water, Apollinaris, Seltzer, or Deep Rock water can be ordered; barley- or rice-water is slightly nourishing and relieves thirst, but all liquids should be given in moderation. When it becomes necessary to give food, the stomach must be made to do the work of digestion, and, as far as possible, of absorption also. Such substances are to be chosen as are converted in the stomach into peptones, and which do not require contact with the intestinal juices for their absorption.

The peptones transformed in the stomach from nitrogenous alimentary principles are highly soluble and diffusible. Milk is better suited to the conditions of intestinal catarrh than any other nitrogenous food. It is palatable, relieves the thirst, and can be taken for a long time without {691} aversion. By removing the cream, the fat, which would require intestinal digestion, is partly got rid of. Skimmed milk does not produce a feeling of distaste and what is called biliousness, as does milk unskimmed. In cases where there is gastric catarrh the milk can be made more digestible by adding an equal quantity of barley-water or rice-water. The casein is then more slowly acted on by the gastric juice and more thoroughly digested. Milk should be given in small quantities at short intervals, as in this way the stomach performs the entire work more thoroughly. If a large quantity is given, a portion of it passes into the intestine unaltered. Buttermilk contains less fatty matter than skimmed milk, and is a pleasant substitute for it. Koumiss, if it could be properly prepared, would be an excellent food for diarrhoea. Even the imperfect imitations are retained and digested when other aliments fail. The whey of milk contains lactin, salts, a little casein, and fatty matter. It may be made by adding to milk rennet, sherry or other wine, cream of tartar, tamarind-juice, or alum. Milk-whey is slightly nourishing, and is said to be sudorific; when prepared with wine it is a mild stimulant well suited to the cases of children.

Where it is desired to give as little work to the digestive organs as is possible, milk and other foods can be given already partly digested, as peptonized milk prepared according to the formulæ of Roberts and Fothergill. Eggs are changed quickly in the stomach. Egg albumen is more easily digested by artificial gastric juice than by pancreatic extract (Roberts). A solution of egg albumen boiled in the water-bath is swiftly and entirely transformed by pepsin and hydrochloric acid. Raw eggs have been thought to be the most digestible, but Roberts found that a solution of egg albumen when raw was very slowly acted on by pepsin and acid, but after being cooked it was rapidly and entirely digested. Eggs are best given, therefore, boiled slightly at a slow heat; when an egg is plunged in boiling water the white sets hard, leaving the yelk soft. The albumen of the white and the yelk should be equally cooked throughout.

Beef-tea is said by the chemist to possess little nutritive value; practical experience convinces the physician that it supports life. Peptonized beef-tea may be substituted when thought best. Animal broths thickened with rice, barley, or with peptonized gruel, as advised by Fothergill, or with the addition of vermicelli, are valuable aids when the palate is capricious. Raw beef is not as digestible as when the tendinous and aponeurotic structures of the muscular fibre have been softened, disintegrated, and converted into the soluble and easily-digested form of gelatin by cooking. Scraped raw beef, when the pulp is removed from much of the connective tissue, is easily digested by children as well as by adults.

In most cases of acute intestinal catarrh the patient can be well sustained by a diet consisting of one or other of the aliments described. For the largest number milk alone--that is, skimmed milk or milk diluted with barley-water, rice-water, or Seltzer water--is all that is necessary to support strength during the attack. Although starch after deglutition is {692} acted on in the intestine only, it becomes desirable sometimes to give farinaceous food in some form or other; milk may be undigested and animal broths may become distasteful; the palate craves some change. In this case a blanc mange made after the formula of Meigs and Pepper is as well suited to adults as to children, the proportion of cream and arrowroot being made larger for adults. Sago and tapioca can be tried to tempt the palate. The flour of the Egyptian lentil is made into a gruel also. Most of the patent foods for infants and invalids contain starch in some form or other. Racahout is one of the pleasantest and best of these. Nestle's food contains baked biscuits of wheat flour ground to a powder. Liebig's food is made of wheat flour, malt flour, and a little bicarbonate of potassium. Revalenta Arabica is an attractive name for the flour of Arabian lentil with barley flour. Any of these may be advantageously employed in cases of some duration and in the later stages of convalescence.

The diet for convalescence should be controlled by the physician until the patient has been well for at least two weeks. Liquid preparations give place to fine hominy, corn meal or oatmeal porridge, with milk. Then bread or crackers may be given, the intervals between the meals increasing to three or four hours. Raw oysters, sweetbreads, tender rare steak or mutton finely divided and well masticated, rice, and ripe peaches, succeed the simpler diet. Much saccharine, starchy, or fatty food is to be avoided for at least two weeks after entire recovery.

When the indications derived from the study of the cause have been acted on, and the patient has been placed under a rigid discipline of rest and diet, the treatment of symptoms comes next in order.

In mild cases, where the cause has been irritating ingesta, diet may relieve the symptoms in a short time without medicine. If diarrhoea with slight colicky pains and flatulence continue after a few hours, a mixture holding in suspension subnitrate of bismuth, with five drops of the deodorized tincture of opium in each dose, or a pill of lead and opium, will suffice in a short time to give relief. In severer attacks the fever heat may mount to a high point, giving great distress to the patient. If a temperature of 103° to 104° F. is reached--which is not unusual in children--a warm bath is a sedative and antipyretic remedy, or a bath of 95° can be gradually cooled down to 75° or 65° F.--a procedure which will bring down the body-heat two or three degrees. A substitution for the bath is sponging with cool or cold water, to which vinegar or bay rum may be added; or towels wrung out of cold water can be applied to the trunk and extremities (Ringer) with a very happy effect.

Quinia can be used antipyretically in full doses, dissolved in dilute hydrochloric acid. Pills, especially the sugar- or gelatin-coated pills, {693} should not be given, as they irritate the mucous membrane whether they are dissolved or not. In diarrhoea quinia pills often pass unaltered.

Flatulence, eructations of gas, and borborygmi are controlled by strict diet according to the rules given. Bismuth subnitrate or subcarbonate unites with sulphuretted hydrogen and absorbs it. The alkalies, sodium and potassium bicarbonate, sodium hyposulphite, the aromatic spirits of ammonia, either relieve acidity or prevent fermentation and the development of gas. A satisfactory formula for the early stages of intestinal catarrh is one containing bismuth subcarbonate, sodium bicarbonate, aromatic spirits of ammonia in water or cinnamon-water. When the abdominal distension is great enough to be a cause of distress, external cold--dry cold--is the best, applied with a rubber bag filled with cracked ice or ice-water; it causes absorption of gas. Abdominal compression with a bandage may be of some service also. Mineral acids, especially the dilute hydrochloric acid, by affording aid to the digestion prevent acid fermentation.

Diarrhoea is the central symptom and the best standard by which to measure the intensity of the catarrh and its progress. But it is only a symptom, and the mind ought to be directed to the lesion and not to it. Having the cause in view, the object in all cases is to allay the inflammation. This done, the diarrhoea decreases, then ceases. Shall the effort be made to check the discharges, or shall they be allowed to continue? The evacuant plan of treatment has been advocated, on the ground that the purgative, by increasing intestinal secretion, relieves the congestion of the intestinal blood-vessels and leaves the membrane in a better state than before. But inasmuch as a purgative only acts by bringing about an intestinal hyperæmia and catarrh, there is no good reason for, and many reasons against, treatment by evacuation.

A preliminary purgative, as has already been stated, is necessary to expel undigested food and scybalæ, but for the purpose of increasing intestinal or biliary secretion and diminishing engorgement of the vessels this method is unsuccessful and unnecessary. When irritating substances have been removed (and this is done usually without the physician's aid by the spontaneous expulsive movements of the bowel) the effort to check the discharge and to give rest is one and the same. Opium is the one invaluable remedy which we cannot do without. As little of it should be given as is necessary to relieve the intensity of the symptoms. The aim should not be to stop the pain and check diarrhoea, but to take the edge off the sharp agony and to lengthen the interval between the stools. Thus gradually the spasms of peristalsis cease, and there is a diminution, and finally cessation, of the fluid accumulation in the bowel. The diarrhoea is relieved entirely in a period ranging from an hour after the giving of the first dose to one week, according to the severity of the attack. Opium is given in pill form, in the deodorized tincture, Dover's powder, or one of the salts of morphia may be preferred. Any of these may be combined with antacid and antifermentative mixtures, relieving the colic, gaseous distension, and diarrhoea. If opium is combined with, {694} or followed by, evacuants, its effects are thwarted, and it might as well not be given at all.

It is the custom to combine astringents with opium, but in acute cases of short duration it is a question whether astringents do not do more harm than good. When good does come from the combination, it is the opium which acts promptly and decidedly. The astringent lags behind, and in cases of some duration and severity supplements the work of the active partner. Bismuth is classed under this head, although it is not an astringent. Its action is mechanical; much that is taken is passed from the bowel as the black sulphide, which appears as a black granular powder in the fluid stool. This is no proof that it may not have been of service in its transit. After death, when large doses have been given, it has been found lining the whole intestinal canal. The subnitrate or subcarbonate can be given in powder on an empty stomach in doses of five to twenty grains alone or in combination with opium, or it can be dispensed with alkalies in water. The enormous doses (one hundred and fifty to nine hundred grains daily), as given by Monneret, are useless or hurtful. The value of bismuth is based on empirical grounds only, but it is irrational to load the bowel with an insoluble powder which if retained must cause irritation. As the discoloration of the stools is an objection to bismuth when it is desired to study their character for diagnosis, oxide of zinc may be substituted for it, as the latter is an absorbent of acids and gases. Gubler has insisted upon combining it with bicarbonate of sodium to prevent the formation of the irritating chloride of zinc in the stomach. One of the oldest and most popular remedies tor diarrhoea is lime in the form of the carbonate or lime-water. The officinal mistura cretæ is perhaps more generally used for children than any other remedy. Lime-water is added with advantage to milk when given to adults as well as children. Carrara-water, made by dissolving the bicarbonate of lime with an excess of carbonic acid, is less nauseous than liquor calcis, and may be mixed with an equal part of milk. Chalk and its preparations are less beneficial than bismuth as astringents, but may be used merely for their antacid effect.

The sugar of lead is a valuable astringent, because unirritating and sedative to the mucous membrane. With opium in pill form, in doses of one to three grains, it checks diarrhoea if the inflammation has not lasted long and is not extensive. If there are cases where the bile is passed in quantity, it is especially called for, as it is the only astringent which diminishes the flow of bile.

The mineral acids--dilute hydrochloric, nitric, and sulphuric acids--are given with some success. The first aids gastric digestion, and in small doses with pepsin can be directed after food irrespective of other treatment. The great repute which it has enjoyed in the diarrhoea of typhoid is no doubt due to the improved digestion and assimilation {695} which follow its use. The acid principle is what is lacking in the gastric juice in fever and debility. In all cases of intestinal catarrh rapidity of gastric digestion should be sought for. Nitric acid is of doubtful utility. Without an opiate in combination there is little reason to hope for any result from its use; all the suggested formulæ contain opiates. Dilute sulphuric acid is thought to be more astringent than the others. If it has any efficacy, it is due to the local astringent or alterative effect by contact with the inflamed surface. Much testimony is to be found in its support in cases tending to become chronic and where astringents combined with opiates have failed after some days' trial. It should be administered in doses of five to twenty drops in the form of mixture with mucilage or some aromatic, as lavender and cardamom. An opiate should not be combined with it if it is desired to test it fairly. It would be called for when the stools are pale, abundant, watery, and alkaline.

Calomel is of ancient repute as a remedy in the early stages of diarrhoea. According to recent views, it acts as a sedative to the gastro-intestinal mucous membrane and checks fermentation. It should be given in small doses (one-twelfth to one-eighth of a grain to children, one-fourth to one-half of a grain to adults); it should not be continued for more than two or three days. In combination with Dover's powder it acts well, but it is doubtful which of the two remedies should receive the greater praise for the resulting improvement. A very small dose of the bichloride of mercury has been found beneficial by Ringer for clayey, pasty stools or straining stools containing slime and blood. His formula is--Hydrarg. bichloridi gr. j; Aquæ fluidounce x; a teaspoonful frequently during the day. The gray powder is not as much thought of now as formerly; it is not so good for the early stages of diarrhoea as calomel, but may be tried as an alterative when the stools are green and offensive.

In the vegetable materia medica there are many and ancient remedies. Tannin represents a large class, and there is nothing more than fancy in preferring to it kino, catechu, hæmatoxylon, or blackberry-root. Tannin is precipitated in the stomach as an inert tannate; gallic acid is to be preferred for this reason, and also for its pleasant taste and less irritating effect on the mucous membrane. It is well borne by children, even in large doses, when given with water and syrup. It is to be hoped that the unsightly and unsavory combinations of the astringent tinctures with chalk mixture will be soon given up. They are given chiefly to children, who are repelled by the sight, and still more by the taste, of such compounds. The syrup of krameria is the least objectionable, and catechu and krameria are made into troches which are sometimes available.

Ipecacuanha is said by Bartholow to be extremely serviceable in the diarrhoea of teething children with greenish stools containing mucus or blood. He prescribes it with bismuth and pepsin.

{696} Recently some favor has been paid to coto-bark and its active principle, cotoin. The latter is advised to be given in the following formula:

Rx. Cotoinæ, gr. j; Aquæ distillat. fluidounce iv; Alcohol, gtt. x; Syrupi, fluidounce j.

A tablespoonful every hour. Five to eight drops of the fluid extract of coto are given. It is said to have a speedy and certain effect in acute diarrhoea.

Salicin, ergot, guarana, have all been spoken of by enthusiasts as possessing valuable properties in diarrhoea.

Alum is not often prescribed. Sulphate of copper is fitted for cases in danger of passing into the chronic stage. Sulphate of zinc might be more generally ordered than is the case. The sulphate of iron and the fluid preparations of iron--tincture of the chloride, solution of the pernitrite, and persulphate--are astringents, and could be tried if other remedies fail. The effect of nitrate of silver is to constrict vessels, to coagulate and disinfect excretions, and to form an adherent protecting membrane (Phillips). It occupies the next place to lead, and is suited to a subacute stage when acute symptoms have subsided. It is warmly recommended by William Pepper and others. The oxide of silver has been preferred by some writers. For the protracted diarrhoea of children, in whom follicular ulcers form so rapidly, the nitrate of silver is of special value. To adults it is administered in a pill freshly made in doses of one-eighth to one grain. A solution in distilled water with syrup answers well for children, the dose varying from one-twentieth to one-fourth of a grain.