Chapter XLII: Front Matter (42)

In uncomplicated mild cases of intestinal catarrh there is a movement toward recovery after a few days' illness. The stools become less frequent, smaller, and more consistent. In a week to ten days the tongue cleans, the thirst ceases, the appetite returns, the tympanites and pain diminish. The fever declines, and ceases before the diarrhoea is completely arrested. There are always more or less emaciation and loss of strength from the fever and arrest of nutrition. The liability to relapse is great, and the patient by indiscretions reproduces the same symptoms, thus prolonging the attack for several weeks. Acute intestinal catarrh may pass into the chronic form by a disappearance of fever and amelioration of all the abdominal symptoms. The patient begins to take solid food, gains strength and flesh, but complete recovery does not come. The diarrhoea recurs at variable intervals as the result of indulgences in a mixed diet, over-exercise, or exposure to cold, and in time we have some degree of chronic catarrh permanently established.

Very mild cases may be prolonged by the neglect of the patient to consider his painless diarrhoea of sufficient moment to need attention.

In inflammation of the more intense kind the picture is somewhat different. The prodromes are longer and the general symptoms more severe. Restlessness, a sense of prostration, delirium, and high fever mark the early stages and continue for a longer time. The patient loses flesh and strength quickly. The features express anxiety and illness, the skin is hot and dry, and the thirst great. Vomiting is repeated. Borborygmi, the tension of the abdomen, pain, and sensibility to pressure are all intensified. The stools are at first yellow and thin, but change much from day to day. They may be green or very thin and dark or grayish, and are sometimes very offensive in odor. Blood and mucus may be seen in them, being slimy or grumous and bloody. When the patient is very weak the discharges are involuntary; the tongue is coated white, with bright red tip and edges, and is often dry.

{682} The severer forms last from three to six weeks. After a tedious period of alternate improvement and relapse the illness becomes chronic or the patient dies from asthenia, perforation and peritonitis, or some other complication.

In the most intense varieties which find examples among Europeans and Americans in intertropical countries, or result from acute mineral poisoning and from rapidly-progressing cases of acute ulceration of the intestinal wall, especially in children, there is a sharper and more violent invasion. The strength is reduced in a very short time, and there is rapid emaciation; the features assume an anxious expression; the complexion is leaden or livid; the skin is cold and clammy; the pulse is small, weak, and rapid; the breath comes quick and short, and is frequently complicated with hiccough. In the early stages vomiting occurs, due to a concurrent gastritis; in cases of poisoning vomiting is incessant.

The pain in the abdomen is intense, and less paroxysmal than in other forms. The abdomen is tympanitic and excessively tender to the touch, and the knees are drawn up to relieve the tension of the abdominal muscles. Thin, black, or reddish stools are passed every few moments. As the attack progresses the urine is suppressed, the voice becomes whispering, and collapse is developed. This is marked by cold extremities, dyspnoea, feeble and finally imperceptible pulse. Death may end the scene in a few hours or the patient may rally and recover slowly.

Choleriform diarrhoea occurs chiefly in children during hot weather.

VARIETIES DUE TO SEAT.--The symptoms and progress of acute catarrh of the intestines present numerous differences depending upon the seat of the inflammation. The symptomatology already given is that of the most common form (ileo-colitis), in which the lower part of the ileum and a considerable portion of the colon are simultaneously involved. Many cases no doubt occur in which the disease is limited and in which early recovery is the rule. The pathological anatomy of cases of generalized catarrh is better known, as they form the bulk of the fatal cases.

I. Acute Duodenitis.--The most common form of duodenitis is that in which the inflammation spreads by continuity of tissue from the stomach to the duodenum, as in acute gastric catarrh after a debauch. The prominence of the gastric symptoms disguises the intestinal lesion, unless the catarrh, as is frequently the case, extends into and obstructs the common bile-duct and its branches, and suddenly develops icterus with clayey stools and altered urine. Besides icterus, a careful isolation of symptoms will show that some cannot be attributed to the stomach: there is a dull pain seated in the right hypochondrium, extending to the right shoulder or shoulder-blade, which is increased by pressure upon the region of the duodenum. As the gastric symptoms improve there is no change in the icterus, which continues for some days or weeks longer. The connection between burns of the integument and ulcer of the duodenum is well known. Symptoms of perforation, with death, may be the first sign of this lesion, but vomiting of blood, icterus, purging of blood, indigestion, and cardialgia occur from duodenal ulcers.

The typical acute duodenitis described by authors as an independent {683} affection is of rare occurrence. An epidemic of duodenitis[26] has been reported where many persons were simultaneously attacked, all the cases having had the same traits--headache, pain in the line of the duodenum at the left edge of the right hypochondrium, pain in the first and second lumbar vertebræ, constipation, jaundice, slow pulse, and mental depression. Gangrenous inflammation of the duodenum[27] has been once seen, and produced a chill, a severe sense of weight and pain in the epigastrium, retching and eructations of gas, tenderness on pressure, frequent pulse, and high temperature. There was obstinate constipation, with dyspnoea, death ensuing in a few days. At the autopsy gangrenous inflammation of the duodenum was found, which ended abruptly twelve inches from the pylorus. There was a large gall-stone in the gall-bladder.

[Footnote 26: McGaughey, _Philada. Med. Times_, Aug. 1, 1872, ii. p. 407; also, T. N. Reynolds, _Detroit Clinic_, June 7, 1882, p. 181.]

[Footnote 27: Eskridge, _Philada. Med. Times_, Feb. 15, 1879, ix. p. 239.]

A fatal case of duodenitis is recorded[28] in which the following symptoms were observed: sudden and severe pain in the right hypochondrium, increased by pressure; rigors, vomiting and purging of a green flocculent fluid, and later of blood; jaundice, fever, delirium, collapse, and death. The pylorus and two-thirds of the duodenal mucous membrane were much inflamed and the orifice of the bile-duct closed.

[Footnote 28: _Die Krankheiten des Duodenums_, Mayer, quoted by Leube in _Ziemssen's Cyclopædia_, Am. ed., vol. vii. p. 373.]

II. Acute Ileitis, Acute Jejunitis.--When the ileum, with or without the jejunum, is the seat of catarrh, diarrhoea may not be present, provided the inflammation is slight and there is no increase of colon peristalsis. The symptoms then are borborygmi, pain and fulness about and below the umbilicus or between it and the right ileum, especially after eating, and the general symptoms arising from indigestion and malnutrition. Fever is slight or absent; there are malaise and loss of strength. The feces give important indications. They contain unaltered bile and fragments of muscular fibre and starch-granules in excess of the quantity found in health. An increased quantity of mucus, diffused evenly in a fluid evacuation, or globules of mucus stained with bile, or bile-stained epithelium, denote inflammation confined to the small intestine. A larger amount of indican in the urine than is normally present is a sign of the same lesion.[29]

[Footnote 29: These conclusions are based upon the results of one thousand examinations of feces made by H. Nothnägel, and reported in _Zur Klinik der Darmkrankheiten; Zeitschrift für klin. Medicin_, iv., 1882, p. 223.]

Intense inflammation of the small intestine may exist without diarrhoea or other symptoms betokening the real nature of the attack. Flint[30] mentions having met with three such instances, and Goodhart[31] records thirteen cases of enteritis with marked lesions in which no diagnosis had been made before death. Rilliet and Barthez report twenty-four autopsies in children with intestinal lesions in which no symptoms had been observed.[32]

[Footnote 30: _Clinical Medicine_, Philada., 1879, p. 280.]

[Footnote 31: _Guy's Hospital Gazette_, Sept., 1878, p. 98 _et seq._]

[Footnote 32: _Maladies des Enfants_, Paris, 1861, tome i. p. 748.]

III. Acute Colitis.--Fifty years ago colitis was synonymous with enteritis, and not with dysentery, as at a more recent date.[33] The older {684} signification expressed the fact that inflammation in the colon is essential to diarrhoea. Later the term was used synonymously with dysentery.[34]

[Footnote 33: _Journal général de Médecine_, Paris, 1825, t. xci. p. 18.]

[Footnote 34: Tweedie, _System of the Practice of Medicine_, 1841.]

The colon is a conducting tube; the contents are composed of matters unabsorbed in the small intestines. At first the mass entering the colon is fluid, but by the gradual absorption of its watery part it approaches solidity. The discharge from the rectum of a fluid shows that the propulsion through the large intestine is so rapid that the process of drying does not take place, or that from inflammation of the colon there is an excess of fluid transudation from the intestinal wall. The superficial position of the colon, its great size and length, expose it to the action of external cold, to blows, etc.

In catarrh limited to the colon there are essentially the same symptoms as in ileo-colitis, inasmuch as the inflammation of the colon gives to that form its characteristic features--borborygmi, diarrhoea, and tympanites. When the disease in the colon preponderates or exists alone, the pain and tenderness are more superficial and confined to the line of the large intestine. The distended colon projects and the abdominal swelling is not so uniform. If the attack is subacute or mild, the stools contain normal feces mixed with a great deal of mucus; when the inflammation is in the sigmoid flexure, pure mucus is passed. Blood mixed with mucus and tenesmus accompany inflammation low down. Blood may, however, come from intense inflammation of the ascending and transverse colon without disease of the lower bowel.[35]

[Footnote 35: In a case seen by the writer of colitis terminating fatally from perforation of the transverse colon this point was illustrated. A woman aged fifty was taken with diarrhoea in August, 1873. In November the symptoms became worse: tongue dry and red; abdominal pain; tympanites; frequent stools, ten to seventeen in twenty-four hours; quantity large, of a yellow or brownish-red color with floating flakes. General symptoms grew worse; blood in stools from time to time. November 24, sudden cessation of discharges from the bowels, and the following day sudden collapse and death. Autopsy: Descending colon and sigmoid flexure comparatively healthy. Transverse colon adherent to stomach; deposits of lymph on colon and small intestines; fluid and feces in the peritoneal cavity. The mucous membrane of the ascending and transverse colon in a state of black pulpy disintegration. In the transverse colon the walls were thinned by ulceration and easily torn; gangrenous appearance of mucous coat; perforation of the colon wall below greater curvature of the stomach.]

IV. Proctitis.--The rectum may be the seat of simple catarrh, which differs in its symptoms from catarrh of other portions of the canal. By many this form is called simple, non-infective dysentery. But as it is a form of intestinal catarrh, it is right that it should be considered in connection with colitis. The first indication of its onset is a frequent desire to go to stool, with an unsatisfied feeling after each effort. Normal fecal matter is first expelled in solid form, coated with mucus which may be streaked with blood. Soon, however, the discharges consist of jelly-like mucus, alone or mixed with blood. A small quantity of this is passed with tenesmus at short intervals. The patient complains of a burning feeling in the rectum and a constant and irresistible desire to strain. The same spasmodic contraction may involve the bladder.

This affection rarely assumes a serious form. It usually ends in recovery spontaneously or under treatment by the cessation of the mucus and blood and the discharge of normal fecal matter.

DIAGNOSIS.--A combination of the symptoms described as belonging to inflammation of the small and large intestine gives the most common {685} form of intestinal catarrh, ileo-colitis. This union is diagnosed by the following symptoms: fever; general distension of the abdomen; paroxysmal pains starting from the umbilicus, but having a general distribution; noisy movements of gas; diarrhoea, the stools being large, thin, stained more or less with bile, containing more or less mucus intimately mixed with fluid matter and with particles of partially-digested or unaltered food. It is possible in many cases to recognize the part of the intestinal canal which is the seat of disease from differences in symptoms which have already been described. But great care in observation is needed, combined with a minute inspection and microscopical examination of the stools, to arrive at accurate and well-founded conclusions.

Acute follicular ulceration may be thought to have begun if after a week or more of illness thin and sometimes putrescent stools are passed containing small blood-coagula, with mucus and pus.[36] This opinion would be confirmed by an increase in abdominal tenderness and the persistence of the diarrhoea or tendency to relapse notwithstanding careful treatment and diet. The transition of the disease into the chronic form would give additional support to this view of the nature of the lesion.[37]

[Footnote 36: "The intestinal mucous membrane, especially that of the small intestine, scarcely ever produces pus without ulceration" (Virchow's _Cellular Pathology_, Philada., 1863, p. 492).]

[Footnote 37: For a more detailed account of the symptoms and diagnosis of follicular ulceration see article on CHRONIC INTESTINAL CATARRH.]

Some or all of the symptoms of acute intestinal catarrh are, however, found in other diseases. It is well, therefore, to devote some attention to differential diagnosis, giving a résumé of the salient points of distinction.

Typhoid fever in many of its features resembles intestinal catarrh, and in many cases is confounded with it. Until within quite recent times the symptoms of typhoid fever were grouped under the names gastro-enteritis and follicular enteritis. In the first week of the illness there is reasonable ground for delay in making a positive diagnosis. Etiological data are here of great help. The occurrence of the symptoms in children under two years and in adults beyond fifty years points strongly to intestinal catarrh. Spring and early summer are the seasons for diarrhoea; typhoid belongs to late summer and to autumn. A sudden onset after errors in diet or exposure to cold, with the early development of pain in the bowels, rumbling of gas, diarrhoea, would be easily recognized as a local disorder. In typhoid fever there is a less sudden onset, with prodromal debility, anæmia, indigestion, and nocturnal fever. To these symptoms the diarrhoea, which is attended with little or no pain, plays a very subordinate part. In many cases of mild typhoid the development is sudden, with rigors. A week's study of the temperature, if no rose-spots appear, will be needed before the diagnosis can be made. There is not much difficulty in making the distinction when the attack has reached its second week. At this period in catarrh of the bowel the high fever, with regular morning remissions and evening exacerbations, is not constant, as in typhoid fever; there is tenderness on pressure over the abdomen and gurgling, but no great meteorism; sibilant râles are not heard in the chest; there are no rose-spots; rarely cerebral symptoms except insomnia; and delirium is uncommon. The spleen is not enlarged. The prostration is proportioned to the diarrhoea, and is by no means as {686} great as at the same period in enteric fever. The colicky pains preceding and accompanying the stools are a more marked feature of intestinal catarrh; they are absent in enteric fever or have a feeble intensity.

In children between the ages of two and seven years there are certain peculiarities which augment the difficulties of diagnosis. Intestinal catarrh in them is accompanied by an abundant, frequently painless diarrhoea, by tympanites, cerebral disturbances, a dry and coated tongue, with sordes on the lips and gums, and by a rapidly-developed anæmia, emaciation, and exhaustion. Typhoid fever in children of this age is generally benignant; vomiting is more common than in adults; high grades of meteorism are infrequent; tenderness of the cæcal region is determined with greater difficulty; and severe nervous phenomena and fatal intestinal complications rarely occur.[38] In other words, in young children intestinal catarrh by its severity and enteric fever by its benignity more nearly approach each other than in adults; in many instances the diagnosis must be undecided until late in the attack.

[Footnote 38: Consult "Diseases of Children," Henoch, _Wood's Library_, New York, 1882, p. 300.]

Typhoid fever can of course be known if rose-spots, a splenic tumor, or the characteristic delirium are manifested, or if the fever-curve conforms to the type; but in children all these symptoms may be negative; even the fever has great variability. If fever is continued beyond ten days, and is accompanied by progressive anæmia and emaciation and debility, the attack is enteric fever if all local causes of fever can be excluded. There is no minimum limit to the temperature in typhoid fever, and no matter how low the maxima of the fastigium may be, typhoid fever cannot be excluded.[39]

[Footnote 39: Johnston, "On the Diagnosis of Mild Cases of Typhoid Fever," _Am. Journ. Med. Sci._, Oct., 1875, p. 372; also, "On the Mild Forms of Continued Fever in Washington," _Am. Journ. Med. Sci._, Oct., 1882, p. 387.]

The large watery stools and the absence of tenesmus mark the difference between diarrhoea and dysentery. Blood may be present in colitis, owing to a high grade of inflammation and to ulceration. Simple catarrh of the rectum, proctitis, is not readily distinguished from infective dysentery. Small mucous and bloody stools may be catarrhal. In the present state of our knowledge dysentery would be known by marked tenesmus, by the grave general symptoms, the reddish fluid stools with flocculi, and by its occurrence in epidemic form.

Enteralgia presents the following features which distinguish it from intestinal catarrh: The tongue in enteralgia is clean or coated white, but with no red tip and edges; the appetite is capricious, but not lost; the bowels are constipated; the pain bears no relation to the ingestion of food or drink, as in enteritis. Fever is accidental, and there are other nervous phenomena. In lead colic there is no fever, tympanites, nor diarrhoea. In rheumatism of the abdominal walls the pain is superficial and sharp, not griping, and is increased by movements of the trunk. The digestive system is in no way disordered. From peritonitis intestinal catarrh is distinguished by a less degree of illness and by its usually favorable result, by diarrhoea, a greater freedom in movement, and by a less degree of suffering on palpating the abdomen. Tympanites, constipation, great tenderness on pressure over the abdomen, and a small, quick pulse, point to peritonitis.

{687} PROGNOSIS.--A simple intestinal catarrh of the form first described involves no danger, and if treated by rest and diet soon recovers. The more severe form, beginning as a primary disease, when rationally treated ends in recovery in most instances.

Unfavorable predisposing causes are--a hot climate (India, the West Indies, and intertropical climates in general); very hot weather of the summer and autumn months; a very early or very advanced age; the contaminated atmosphere of prisons, camps, etc.; all bad hygienic influences; and previous or coexisting illness. When diarrhoea occurs as a complication of the acute infectious diseases it has a special gravity. In typhoid fever, scarlatina, measles, acute tuberculosis, etc. it adds another element of illness and danger. During the progress of chronic general diseases (malaria, scurvy, tuberculosis) it becomes an obstinate and sometimes a fatal complication. Among the exciting causes mineral poisons induce the most dangerous form of intestinal catarrh. Unfavorable symptoms occurring during the course of acute diarrhoea are the early development of high temperature, cerebral disturbance, great sensibility to pressure over the abdomen, thin and bloody or highly offensive stools, involuntary discharges, and very rapid emaciation and loss of strength.

TREATMENT.--There have been many fluctuations of opinion as to the relative value of modes of treatment in this disease. Various therapeutic measures have been suggested which, after enjoying favor for a time, have been abandoned, and revived after long periods of disfavor. Venesection was alternately recommended and forbidden. Emetics and evacuants, mercurials, diuretics, diaphoretics, have been in turn warmly supported and vigorously opposed. Opium, belladonna, the various astringents, and cinchona-bark have run through many changes of favor. Individual drugs give curious evidence of inconstancy. Oxide of zinc, suggested by James Adair in 1785 and by Hendy in 1784, after a hundred years of weak approval is commended highly by Penrose (1863), Brakenridge, and Mackey (1873),[40] and by more recent writers. Acetate of lead, which dates back to Paracelsus, had varying fortunes of repute and disrepute. In the end of the seventeenth century it had a name for curing diarrhoea, but in the following century it was spoken of by Boerhaave as a deceitful and destructive poison, and Cullen in 1789 said that hardly any one then thought of using lead internally.[41] In 1799 it had warm advocates in this country; among them, Thomas Ewall of Washington, who wrote in 1808. Since then it has come into very general use and favor, which it still holds.

[Footnote 40: J. J. Woodward, _op. cit._, p. 776.]

[Footnote 41: Ibid., _op. cit._, p. 780 _et seq._]

In view of the many changes of faith in systems of treatment and in drugs, we have no right to assume that we have as yet reached the perfection of treatment. In fact, experience brings the conviction that our systems are quite imperfect and that drugs fail in our hands when they are most needed.

The prophylactic treatment is of importance, especially in children, delicate persons, and in those suffering from disease or predisposed by idiosyncrasy to intestinal catarrh. Directions must be given by the physician as to the food for children appropriate to their age and digestive capacity. Summer heat and city life being so fatal to them, they should {688} be sent to the cool climate of the seashore or mountains during the first and second years of life. In warm weather laxatives should not be given to children, except with precautions against their acting too freely; the same rule applies to the aged. Too great care in diet in older children predisposes to indigestion and diarrhoea. Variety in food is of service, therefore. It is not well to give children food prepared so as to do away with the necessity for mastication and for active gastric movements. The stomach gains strength by exercise. All reasonable care should be used not to take food in excess of the individual's power of digestion. Unripe fruit, stale vegetables or fruits, cheese, pork, shellfish which are not absolutely fresh, are among the aliments which may produce diarrhoea, and are to be avoided. Many people have to be told what food is unsuited to them, and certain articles of food in individual cases invariably excite diarrhoea. Alcohol is often to be blamed for diarrhoeas which are attributed to indigestible food, and frequent recurrences of intestinal catarrh can only be prevented by abandoning stimulants altogether. The bad effects of sudden changes in temperature are warded off by wearing flannel next to the body. This is an important rule for adults as for children. Even in summer thin flannel or gauze gives protection. Well-ventilated rooms, good house-drainage, personal cleanliness, with all other hygienic aids, are means of prevention. Persistent disinfection of sources of air- and water-contamination should be practised, especially in hot weather. In the country the open privies and wells need frequent clearing out. Cases of fatal diarrhoea are met with in elevated regions where the continued low temperature renders it improbable that heat could have anything to do with their causation.[42] Water should not be used which could in any way be tainted with soakage from privies, barnyards, or other places where animal decomposition is going on.[43] Avoiding the use of cathartics in the onset of acute illness, the nature of which is not known, is a useful prophylactic measure. A fatal diarrhoea may result from injudicious purging in such cases. Care in the use of laxatives should be observed in the chronic wasting diseases--tuberculosis, rachitis, cancer, etc.

[Footnote 42: The yearly occurrence of typhoid fever and diarrhoea at seashore hotels shows that there is great danger in crowding persons together and saturating the soil with the excreta. In the summer of 1882 in a boarding-house in the mountains of Maryland, where the temperature was never above 75°, there were three fatal cases of diarrhoea in children, and several others of diarrhoea and dysentery which recovered.]

[Footnote 43: The drinking-water supplying a country boarding-house visited by the writer passed through iron pipes imbedded in the manure-heap of a barnyard.]

The selection of a plan of treatment for intestinal catarrh will depend upon the nature and cause of the symptoms. The diagnosis of the case is incomplete and the treatment irrational until the indications furnished by etiology have been obtained.

If cold has been the exciting cause, the patient should be confined to bed. In the beginning a full dose of pilocarpin, hypodermically,[44] or of the fluid extract of jaborandi by the mouth, may cause a powerful diversion from the bowel to the skin. A hot-water or vapor bath has the same object in view. Hot fomentations or mustard poultices can be next applied to the abdomen. This should be succeeded by a febrifuge {689} mixture containing the tincture of aconite-root, to which an opiate (the deodorized tincture of opium or morphia) is to be added if there is much pain or diarrhoea. A hypodermic injection of morphia given on the first day of the attack immediately after a hot bath will give a quiet night and diminish the intensity of the illness. The subsequent treatment is that common to all the acute forms.

[Footnote 44: Atropia can be given with pilocarpin to diminish its effect on the heart; atropia is the antidote for pilocarpin. (See Schuk, _Centralb. f. d. med. Wissen._, Bd. 20, 1882, p. 357; also, Frohnmüller, _Med.-Chir. Centralb._, July 14, 1882.)]

If summer heat has been the cause in adults or children, artificial cooling of the temperature of the room by the evaporation of ice-water or by one of the refrigerating machines yet to be perfected meet the indication. If there is much body-heat (thermic fever), cold sponging, the application of cold to the head, or the giving of pounded ice to satisfy the intense thirst, are all advisable. Such cases are benefited by a change of climate when the acute symptoms subside. The form of diarrhoea due to malaria is to be treated by quinia and change of air to a more healthful climate. Iron, with quinia or arsenic, is needed in obstinate cases.

Intestinal catarrh which proceeds from the presence of undigested food or hard fecal lumps in the bowel is benefited by early removal of the irritating cause. It is not often that substances of this kind are retained when the stools are large and frequent. The peristalsis is here as active as it need be, and no good, but only harm, can come from over-stimulating the contractile muscles. In those instances where there is a distinct history of the taking of indigestible food, especially fruit with seeds or skins, and where the efforts at stool are frequent, ineffectual, and accompanied by colic and borborygmi, or where scybalæ are found floating in the fluid passed, a large enema of warm water given slowly will excite the bowel to successful expulsive efforts. If this does not give a certain amount of prompt relief, a moderate dose of castor oil, calomel, Rochelle or Epsom salts ought to be prescribed, and repeated after some hours until a free fluid or semi-fluid stool results; one or two doses will usually suffice. If the inflammation is localized in the cæcum (typhlitis), as indicated by local pain, tenderness on pressure in the right iliac or right lumbar regions, constipation, flexing of the right thigh on the trunk, and vomiting, a purgative should not be given, nor should prolonged efforts be made to empty the bowel by injection through long rectal tubes. If there is doubt as to whether typhlitis or undigested food and fecal impaction is the cause of the local pain, it is better to err on the safe side, and not to give a purgative unless the case is seen in the onset before the more pronounced symptoms appear; then calomel or castor oil may be tried once, but not repeated in case of failure.

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,[45] 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.

[Footnote 45: Niemeyer, _Practice of Medicine, Intestinal Catarrh_.]

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.[46] 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.

[Footnote 46: J. M. Fothergill, _Indigestion and Biliousness_, New 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.]