Part 120

1. The mildest form of intestinal catarrh characterized by intestinal indigestion and constipation or by the passage of fecal matter more or less solid, mixed or coated with mucus, is best treated by a diet such as is advised for intestinal indigestion, bathing with friction, outdoor life, exercise on horseback or by walking, pleasurable occupations, and travel. Iron if there is anæmia, and strychnia if there is a sluggish capillary circulation, with cold hands and feet, are available and useful in many cases. Massage and the Swedish movement treatment find useful application in feeble men and in women who are not strong enough for outdoor exercise. To aid the digestion the liquor pancreaticus as advised by Roberts, a teaspoonful one hour and a half to two hours after each meal, with ten to twenty grains of the bicarbonate of sodium, is, theoretically at least, to be warmly recommended. The Rockbridge alum water, a small glass three times daily between meals, has astringency enough for the hyperæmic membrane and is of good service without increasing constipation.

Purgatives should be avoided as much as possible. An enema of cool water, not more than a tumblerful, taken each morning after breakfast if persevered in, may do all that is needed in this direction. If it fails to empty the bowel completely, a larger enema of warm water--one pint--holding in solution sulphate of zinc or alum in the strength of one grain to three or four ounces, can be thrown high up with a rubber tube once daily. This acts upon the mucous surface, constringes mildly the congested vessels, and when expelled brings away the retained fecal matter. These astringent rectal injections offer promise of cure in many obstinate cases where the colon is chiefly the seat of disease. Belladonna is advised for cases of this kind in combination with strychnia for the constipation. Mild laxatives are often necessary. Bedford mineral water, Hunyadi water, or other salines and the less active vegetable {715} cathartics, can be given alternately. Ipecacuanha has had quite a reputation in combination with purgatives in intestinal catarrh. Aloin pills empty the bowel without much attendant irritation.

2. The form of catarrh which shows itself in a tendency to diarrhoea from indiscretions in diet or from exposure to cold must receive prophylactic treatment. Especially in this form is it important to improve the activity of the skin by bathing and friction, and to lead a temperate life in all things, regulating the diet according to the rules already stated. Tonics are called for in such cases. Fowler's solution of arsenic (one drop before each meal, Ringer), the potassio-tartrate or the tincture of the chloride of iron, dilute sulphuric acid, nitro-muriatic or hydrochloric acid, are efficient in improving digestive activity or in opposing the anæmia which is nearly always present. Quinia is indicated in malarial anæmia with a disposition to loose bowels. Quassia or other vegetable bitters can be given if the appetite is languid; the bitters are, as a rule, of little benefit, and may do harm if diarrhoea exists. Strychnia with quassia or columbo stimulates the appetite and the gastric digestion. When intercurrent attacks of diarrhoea come on with coated tongue, flatulence, distress about the umbilicus after eating, bismuth given on an empty stomach in full doses is serviceable. Small doses of morphia or of opium in some form can be added to the bismuth if there is much pain or when the stools are frequent.

In this and in other forms of intestinal catarrh mineral waters are profitably employed. They are best taken at their sources; and here, as in the case of sea-bathing, the benefit is largely due to the change of air and scene and to the more simple mode of life. Any of the watering-places where alkaline-saline waters or ferruginous waters are found may be of benefit. A trip to Europe and a stay at Carlsbad will break up many an obstinate case of chronic abdominal disorder; but other beneficial waters in Europe are Tarosp, Rohitsch, Marienbad, Kissengen, and Plombières.

In this country the comfort and conveniences of the summer hotels and climate are as much to be considered as the chemical composition of the waters. For milder forms of catarrh with constipation a season at Saratoga, with a life of temperance there, is a wise procedure. Bedford Springs, Pa., offer the same advantages in part, but the waters are best suited to catarrh with constipation. Many of the Virginia springs benefit health-seekers who do not place too much reliance upon the virtues of the waters, and who trust to the value of pure air, exercise, diversion, and rest.

3. All plans of treatment for the more severe form of catarrh with chronic diarrhoea (follicular enteritis) must be based upon a knowledge of the lesions. Bearing in mind the alterations in the mucous and submucous tissues, it is clear that no treatment can be successful which is not carried out with the most careful attention to details, and which is not continued for some time after all the symptoms of the disease have ceased. The complete resolution of hypertrophied glandular tissue, the scattering of cell-accumulations, and the healing of ulcers can only be secured in this way. It is best to present the whole case before the patient, so as to enlist in the task his intelligent co-operation.

Directions for the guidance of cases of this kind must include every {716} detail of the patient's life. The question of residence is of importance to begin with. A cool and dry climate is better than a wet and warm one, and where other means fail change of climate is sometimes the only cure. A sea-voyage, a residence in a mountain-region, will oftentimes promptly and effectually cure an obstinate diarrhoea. House-drainage and ventilation should be examined into and improved. The occupation may have developed the disease; in overwork may lie the origin and the cause of its continuance. Rest from work is therefore in some instances the one thing needed. In all cases the energies and the brain should not be overtaxed. The bath to keep the skin active can be combined with friction. The hot bath, as hot as can be borne, is the best. It is a stimulant, not a depressant, as is the tepid bath, and it is safer than the cold bath.

The cold sitz bath or the application of cold compresses diminishes abdominal plethora, and is wisely advised in strong persons who are not depressed or chilled by external cold. Sea-bathing is another hydro-therapeutic measure which is of unquestioned advantage in all forms of intestinal catarrh.

Permanent baths have been found very serviceable in many chronic diseases, and there are many reasons for advising them in obstinate diarrhoeas. There can be no better means for bringing to bear a strong and continued influence upon the intestinal mucous membrane. The patient should be kept in the warm bath for one, two, or three weeks, according to his strength and the effect upon the disease. Systematic hot bathing under the direction of a physician at Richfield, Sharon, the Hot Springs of Virginia or Arkansas, is an invaluable aid.

Rest in the recumbent position for cases where the symptoms indicate marked tissue-alteration is very often the most important part of the treatment. Rest and diet are alone necessary to cure many cases, and without these combined means relief is often impossible. The rest should be absolute, the patient using a bed-pan and lying down all the time. The contraindications for this method are a slight diarrhoea which yields to other treatment, and loss of strength and appetite from the deprivation of air and exercise.

If rest is not advisable, or does no good after a fair trial of two to four weeks, outdoor life in fair weather by driving or walking slowly can be suggested. A long drive will bring back a diarrhoea which has taken many weeks to relieve.

The rules for diet must be clearly given and strictly enforced. An exclusive milk diet should have a trial in every case. Skimmed milk can be taken in larger quantities and with less repulsion, and is therefore to be preferred. The exclusive milk diet can be varied with buttermilk, koumiss, or wine-whey; and fruit-juices, as orange-juice, lime-juice, or tamarind-water, please the patient without doing harm. In the case of adults as well as children the milk is made more digestible by diluting it with barley- or rice-water or by adding transformed farinaceous food to milk in the form of Mellin's food and other foods of this class.

Animal broths, as chicken-soup and beef-tea, are well digested if properly made and given in small quantities. Raw meat scraped, beef or mutton rare and thoroughly masticated, the breast of poultry, game, broiled fish, raw oysters, raw or very slightly boiled eggs, or sweetbread, are foods from which selection can be made to add variety to the dietary. {717} Saccharine, starchy, and fatty foods are to be given as little as possible. Vegetables may be added to the list as the condition improves. Rice and fine hominy (grits) are to be thought of first, as being easily digested and nourishing. Good wine in moderation is not hurtful; the red wines diluted with water are the best, but good port, tokay, and whiskey well diluted find application in particular cases.

Whatever food be given, it should be taken in the quantities and at hours prescribed by the physician, who by careful inspection of the stools judges of the necessity of changes in his regulations and of the success of his treatment.

The further treatment of chronic diarrhoea has for its object by the aid of drugs to change the anatomical state of the mucous membrane. Manifestly, the choice depends upon the state of this tissue. In the earlier stages the increased vascularity and hypersecretion call for mild astringents or for medicines which are believed empirically to oppose these conditions. When drugs can be dispensed with, it is better to do so; they should always be made subordinate to the careful regimen already described.

Bismuth in large doses (ten to thirty grains) is a safe and efficacious remedy in this stage. Nitrate of silver in pill form (one-sixth to one-fourth of a grain) has the endorsement of Wm. Pepper and many other practitioners. It should be continued for two or three weeks at least, but it may be given in small doses during several months, with intermissions, without danger of silver staining.

A routine administration of any drug or class of drugs is reprehensible, and from the numerous remedies which are advocated in chronic diarrhoea selection can be made for trial in the course of intractable cases. The list would include sulphate of copper (one-fourth to one-half a grain), the liquid preparations of iron (liquor ferri nitratis, tinct. ferri chloridi), dilute nitric and sulphuric acids, gallic acid and other vegetable astringents, oxide or sulphate of zinc, alum, precipitated phosphate of calcium, salicin, corrosive sublimate (1/100 gr. every hour), the Indian bael-fruit, etc. No remedy should be abandoned until it has been continuously given for one or more weeks.

The Rockbridge (Va.) alum water is markedly astringent, is not unpleasant, and may be used as a substitute for water with advantage. In fact, there is no better way of introducing in quantity a mild astringent into the intestine than by the drinking of this water.

Cold-water rectal irrigation has a sedative and astringent influence, and when properly used is of great advantage to both children and adults. The patient should be placed in the proper position, and the water made to enter the rectum as high up as possible. The number of stools lessens almost immediately after this treatment, peristalsis being inhibited thereby.

To the water used in irrigation astringents may be added in small doses. Sulphate of zinc, sugar of lead, or alum may be given in this way in the strength of one grain to four or six ounces of water. This {718} method of treatment promises more and is more rational than the internal administration of drugs.

Opium and its preparations should be avoided except to control frequent or watery discharges or to relieve pain, but it is not often that this is called for if wiser measures are first employed. Any of the remedies spoken of may be given in the form of suppositories with greater advantage often than by the mouth.

In that more severe class of cases called follicular ulceration, in which the follicles are known to be ulcerated from a prolongation of the illness, the obstinacy of the diarrhoea, the character of the discharges, and the effect upon the general health, other measures are to be adopted. The diet should be most strictly regulated and the digestive power of the patient carefully studied. Cod-liver oil is added with advantage to other foods if there is a lack of nutrition. Aids to gastric digestion are called for.

The intestinal lesion is to be reached through the stomach or the rectum. Nitrate of silver in small doses is more especially applicable, and is to be preferred to all other drugs in this stage. It is to be given in small doses and for several weeks.

Turpentine and copaiba have something in their favor in ulceration. Ergot has been suggested, and where there is much hemorrhage from the bowel may be prescribed.

Irrigations with solutions of nitrate of silver seem to be a direct and certain remedy in cases where ulceration has existed for a long time. Two and a half to three pints of distilled water, holding in solution five grains of nitrate of silver, should be thrown up the rectum as high as possible with a rubber tube; the effort should be made to secure immediate exit to the fluid. This procedure is to be repeated after the bowels are moved--once every day or every other day if the rectum becomes irritable.

{719}

CHOLERA MORBUS.

BY W. W. JOHNSTON, M.D.