York, 1881, p. 63 _et seq._ See also quote to article on CHRONIC
INTESTINAL CATARRH.]
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.[47] Scraped raw beef, when
the pulp is removed from much of the connective tissue, is easily
digested by children as well as by adults.
[Footnote 47: Ibid., _op. cit._, p. 47.]
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,[48] the proportion of cream and arrowroot being made larger
for adults. Sago[49] and tapioca[50] can be tried to tempt the palate.
The flour of the Egyptian lentil[51] 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.
[Footnote 48: Meigs and Pepper, _Diseases of Children_, Philada., 1870,
p. 304.]
[Footnote 49: Put half an ounce of sago into an enamelled saucepan with
three-quarters of a pint of cold water, and boil gently for an hour and
a quarter. Skim when it comes to the boil, and stir frequently. Sweeten
with a dessertspoonful of sifted loaf sugar. If wine be ordered, two
dessertspoonfuls; and if brandy, one dessertspoonful.]
[Footnote 50: Half an ounce of the best tapioca to a pint and a quarter
of new milk. Simmer gently for two hours and a quarter, stirring
frequently; sweeten with a dessertspoonful of sifted sugar.]
[Footnote 51: Take three tablespoonfuls of lentil flour, a
salt-spoonful of salt, and one pint of water. Mix the flour and salt
into a paste with the water and boil ten minutes, stirring (_Food for
the Invalid_, Fothergill and Wood, New York, 1880).]
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.[52] 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.
[Footnote 52: Woodward, _op. cit._, pp. 727, 728.]
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.[53] 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.
[Footnote 53: The objections urged against opium, that it increases
thirst and nervousness, causes a retention of fermenting products,
produces opium intoxication, and that it is a routine practice to give
it, and does not cure the inflammation, may be valid, but we cannot do
without opium, nevertheless.]
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.[54] After death, when large doses have been
given, it has been found lining the whole intestinal canal.[55] 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.[56] Gubler has insisted
upon combining it with bicarbonate of sodium to prevent the formation
of the irritating chloride of zinc in the stomach.[57] 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.[58] Chalk and its preparations are
less beneficial than bismuth as astringents, but may be used merely for
their antacid effect.
[Footnote 54: Headland asserted that bismuth was insoluble, but it has
been detected in the liver, in milk, in urine, and in the serum of
dropsy by Orfila, Sewald, Bergeret, and Mayençon (_Materia Med._,
Phillips, vol. ii. p. 81).]
[Footnote 55: Levick, _Am. Journ. Med. Sci._, July, 1858, p. 101.]
[Footnote 56: Bonamy, "Du Traitement des Diarrhées rébelles par l'Oxyde
de Zinc," _Bull. gén. de Thér._, t. xcii., 1877, p. 251; also, J.
Jacquier, _De l'Emploi de l'Oxyde de Zinc dans la Diarrhée_, Paris,
Thèsis, 1878, No. 118.]
[Footnote 57: Gubler, _Principles of Therapeutics_, Philada., 1881, p.
25.]
[Footnote 58: Phillips, _Materia Medica_, vol. ii. p. 105.]
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.[59] 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.[60] 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.
[Footnote 59: Manassein, _Virchow's Archiv_, lv., 1872, p. 451.]
[Footnote 60: The favor in which nitric acid is held is due to the
advocacy of nitrous acid by Hope ("Observations on the Powerful Effects
of a Mixture containing Nitrous Acid and Opium in curing Dysentery,
Cholera, and Diarrhoea," _Edin. Med. and Surg. Journ._, vol. xxvi.,
1826, p. 35). Nitrous acid, the same as the fuming nitric acid of the
shops, is a reddish-yellow fluid highly charged with nitrogen trioxide.
Hope said that ordinary nitric acid did not produce the same effects,
and yet nitric acid is now given with the belief that it is of
service.]
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.[61]
[Footnote 61: Coto-bark was imported into Europe from Bolivia in 1873,
and was called quinquina coto. Wittstein of Munich and Julius Jobst of
Stuttgart made the first analyses (_Neues Repertorium für Pharmacie_,
xxiv. and xxv.). Von Gietl (_idem_, xxv.) first concluded from
experiments that it was of use in diarrhoea. Cotoin and paracotoin were
separated by Jobst. It has been found successful in the treatment of
diarrhoea in Germany and of cholera in Japan (Baelz, _Centralb. f. d.
med. Wissen._, 1878, xvi. p. 482). Cotoin sometimes disturbs the
digestion to a marked degree. Paracotoin may be used hypodermically.]
Salicin,[62] ergot, guarana, have all been spoken of by enthusiasts as
possessing valuable properties in diarrhoea.
[Footnote 62: Lawson, "Diarrhoea and its Treatment at the London
Hospitals," _Med. Times and Gaz._, vol. ii., 1868, p. 122; Bishop,
"Salicin in Diarrhoea and Dysentery," _Southern Med. Rec._, vol. iv.,
1874, p. 585; "Comparative Value of Opium and Salicin in Diarrhoea and
Dysentery," _Detroit Review of Med. and Pharm._, vol. x., 1875, p.
387.]
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.[63] The oxide of
silver has been preferred by some writers.[64] 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.
[Footnote 63: J. Maggregor, "On the Internal Use of Nitrate of Silver
in Inflammation of the Intestines," _Lancet_, 1841, vol. ii. p. 937.]
[Footnote 64: Lane, _Med.-Chir. Rev._, July, 1840, p. 289 _et seq._;
Eyre, _The Stomach and its Difficulties_, London, 1852.]
The theory of the germ origin of diarrhoea has naturally brought into
notice antiseptic remedies. Carbolic acid,[65] creasote,[66]
naphtha,[67] sulpho-carbolate of calcium,[68] salicylic acid,[69] and
chlorine-water have each been advocated. Practice does not support
their claim to be considered remedies for intestinal inflammation.
[Footnote 65: Habershon, _Lancet_, London, 1868, vol. i. p. 7; C. G.
Rothe, _Berliner klin. Wochenschrift_, 1871, p. 527.]
[Footnote 66: _Southern Med. and Surg. Journ._, vol. ii., 1846, p. 583;
_ibid._, vol. iii., 1847, p. 147; _London Med. Gaz._, vol. ix., 1849,
p. 254; _ibid._, vol. xii., 1851, p. 235.]
[Footnote 67: _Gaz. des Hôpitaux_, 1849, p. 46.]
[Footnote 68: _Tr. Obstet. Soc. Lond._, vol. xii., 1870, p. 12.]
[Footnote 69: W. Wagner, _Kolbe's Journ. für prakt. Chemie_, Bd. xi.,
1875, S. 60.]
{697} Treatment by the rectum may be employed when medicines are
rejected by the stomach or when it is desired to bring the drugs into
more direct contact with the inflamed colon. Opiates, astringents, and
alteratives are employed in this way. Laudanum in two to four ounces of
warm water or in warm milk or starch-water can be thrown into the
rectum, the fluid being allowed to remain. The injections are to be
given often enough to relieve pain and lessen the number of discharges.
With the laudanum, or without it, the mineral astringents can be used
by enema. Acetate of lead or sulphate of zinc is to be preferred. The
objection that but a small portion of the inflamed surface is reached
by the fluid is a valid one, and therefore those cases are most
benefited where the catarrh is in the lower colon and rectum.
Ringer[70] says that it is not at all necessary for the fluid to reach
that part of the intestine which is the seat of the catarrh; the
impression made on one part is communicated to the other by sympathy.
It was the practice with O'Beirne,[71] Hare,[72] and others to inject
fluid by a long flexible tube passed beyond the sigmoid flexure. This
method is advocated and employed in Europe by Mosler, Winterinz, and
Monti. Quite recently Dulles has drawn attention to irrigation of the
large intestine as a means of treating inflammation of the colon,
according to the plan of Alois Monti of Vienna.[73] Henoch has tried
with partial success in children the throwing into the rectum of a
large quantity of water holding in solution acetate of lead, alum, or
tannin. His method contemplates medication above the sigmoid flexure; a
part of the fluid escapes, while the rest remains five or ten minutes
in the bowel.[74] Monti says as much as two pints can be injected into
the bowel of a nursing child--for older children twice this quantity.
[Footnote 70: _Therapeutics_, New York, 1882, p. 99.]
[Footnote 71: _New Views of the Process of Defecation_, Washington,
1834, p. 85.]
[Footnote 72: E. Hare, "On the Treatment of Tropical Dysentery by means
of Enemata of Tepid Water," _Edin. Med. and Surg. Journ._, vol. lxxii.,
1849, p. 40.]
[Footnote 73: Dulles, "Irrigation of the Colon," _Philada. Med. News_,
Aug. 19, 1882, p. 199. The patient is placed on the side, back, or on
belly, with the hips elevated. A large flexible catheter if a child, a
stomach-tube if an adult, is inserted into the rectum. The tube is
connected with a reservoir of water elevated above the patient. The
rectum is first distended with water, and the tube is gradually made to
follow the course of the bowel until it finds its way into the
descending colon. Thus the water may be made to distend the whole of
the colon to the cæcum. The fluid remains from a few minutes to half an
hour.]
[Footnote 74: Henoch, _Diseases of Children_, Am. ed., New York, 1882,
p. 206.]
Messemer[75] reported three cases (one child and two adults) treated in
this way with the most striking success. His object at first was to
cleanse the rectum, but warm water did not check the diarrhoea. Cold
water was tried, and (probably by reflex influences) diminished rapidly
the number of the discharges. And Ewald[76] has imitated Messemer's
method with results which are surprisingly good. He injected 200 and
300 cc. of cold water, which was expelled by pressure on the abdomen;
50 cc. were then thrown in and allowed to remain. He has used the
treatment in a large number of cases in children. The question as to
the ability to force water thrown into the rectum through the sigmoid
flexure and distend the colon has been settled by the experiment of
Mosler in a case where there was a cæcal fistula. Water injected into
the {698} rectum traversed the colon and escaped through the fistula in
two minutes.[77]
[Footnote 75: J. B. Messemer, "Cold-Water Enemata as a Therapeutic
Agent in Chronic Diarrhoea," _American Journal of the Med. Sci._, vol.
lxxvi., 1878, p. 133.]
[Footnote 76: _Lectures on Digestion_, New York, 1881, p. 149.]