person, a larger dose will have little or no effect, save causing severe pain. If the right time can be selected, a mild purgative will be of the greatest use, and may possibly have the effect of preventing an attack of illness. This variability in the action of the same medicine is very remarkable in the case of mercury, an extremely small quantity of which has sometimes the most beneficial effect in dissipating symptoms which for several days may have indicated serious general disturbance and the derangement of more than one important organ of the body.

DIARRHOEA.

I pass now to the consideration of a condition the very opposite of constipation. Diarrhoea (dia, through, pew, I flow), though a common ailment, is less frequent than constipation, and is seldom habitual and persistent, lasting perhaps for the greater part of a lifetime, like the tendency to constipation. Now and then, however, you do meet with people who seem to suffer very frequently from a condition to which the term diarrhoea would be generally applied. To your inquiry if the bowels are open the patient will perhaps reply "Too much so. On further questioning, you find that the bowels act three or four times every day. In some of these cases the patients do not appear to suffer pain, nor do they necessarily get thin and weak, or appear to be out of health. Whether the looseness depends upon a highly irritable state of the nerves of the mucous membrane, or is due to weak vascular walls, or to an altered state of the blood, or to a highly nervous disposition, it is often difficult to decide. In some cases the condition results from a peculiar habit of body, and undoubtedly there are types of constitution which are remarkable for the great activity of various secreting glands, just as there are others as remarkable for slow and imperfect action. In neither case is there any structural alteration; but one class is characterized by rapid, the other by sluggish, change.

That diarrhoea may be produced through nerve influence only, is proved by a number of circumstances. Many nervous people are very subject to it. Fright, anxiety, and sudden joy may be immediately followed by diarrhoea. Many students who have been exceedingly anxious concerning examinations, have experienced the influence of the mind acting through the nervous system upon the secreting glands which discharge their contents into the intestinal canal. The action is due mainly to a relaxation of the muscular fibres of the small vessels, permitting dilatation and a free discharge of fluid from the blood directly into the bowels, as well as indirectly into the secreting glands.

To those who suffer from constipation, an occasional attack of diarrhoea is very advantageous, and is not to be regretted. Probably diarrhoea carries off many noxious materials that have accumulated in the blood, and may therefore be beneficial to some organisms, provided

CHANGES IN DIARRHEA.

145

it only occurs now and then, and does not last for too long a time, and is not allowed to become very severe at a time when there happens to be an epidemic. But you must not forget that an attack of typhoid fever is often ushered in by slight and sometimes by severe diarrhoea. There is usually a very decided rise in temperature, which in many cases will enable you to form an opinion as to the nature of the malady.

There are times when diarrhoea must be guarded against, and, if it occurs, must not be allowed to persist. During an epidemic of cholera, a person suffering from diarrhoea must be very carefully watched, for, if the condition continue unchecked for even a short time, it may become choleraic. In cholera-times what appears to be ordinary diarrhoea may be succeeded in the course of a few hours by the collapse stage of cholera. The disease usually begins with slight purgation, and you cannot tell whether a person is going to have a mild attack of ordinary diarrhoea or actual cholera. It therefore behooves us to be on our guard, 'and, during the prevalence of a cholera epidemic, it is important to at once check all cases of diarrhoea.

The commonest form of diarrhœa is that which we meet with in hot summers, and often prevails to a great extent in autumn. This is often called summer diarrhoea, and it is hard to say exactly what occasions it. Certain it is that it is more prevalent in hot, dry summers, than it is in cold, wet ones. Some would explain the fact by the superabundance and cheapness of fruit in the former, and its scarcity and high price in the latter. Plums usually get the credit of exciting diarrhoea, but the condition frequently shows itself before plums are obtainable. No doubt bad, unripe fruit, and decaying fruit are very liable to irritate the bowels, and may excite diarrhoea. Neither is there any doubt that decomposing vegetable and animal matter will bring on an attack of diarrhoea; but what the particular organic material may be which exerts the deleterious influence, I do not know. On the other hand, it is quite certain that many of us can eat very considerable quantities of any ordinary fruit without suffering in any way, and even without the ordinary half-constipated habit being relieved. In summer, the intestinal canal of many persons seems to be in an unusually sensitive or irritable state, so that very slight errors in diet are apt to derange its action for a time. Even a little beer that is out of order, or sour milk, will sometimes set up a very troublesome attack of diarrhoea, which may last for days, and require careful treatment to check it.

Concerning the precise changes which occur in severe diarrhoea, little is positively known. It is generally supposed, as I have already remarked, that much of the fluid escapes from the capillary vessels; but at least, in some cases, it is more probable that the condition depends upon increased activity of many of the glands which discharge their contents into the intestinal canal. In sudden diarrhoea, depending upon the presence of some irritating material, I suppose transudation of fluid takes place from

146

IRRITATIVE DIARRHEA.

the vessels, as well as increased secretion from the glands. In many cases, for some time before the attack, it is probable that the blood has been in an unhealthy state, in which case the free discharge of watery matter will be of advantage to the patient, inasmuch as various noxious materials will be eliminated, which would do harm if they were retained in it in a state of solution. Thus by the attack of diarrhoea is the blood depurated, and may, in this way, be soon restored to its normal healthy state. Unquestionably, therefore, in such a case, diarrhoea may be regarded as conservative and advantageous.

Suppose a child has been eating a quantity of unripe fruit,—and it is nothing very unusual for an English baby to eat half a dozen unripe and very uninviting looking apples,--this will soon produce an effect, the stomach and bowels will be irritated, and a sudden, and it may be, violent derangement will follow, often accompanied by feverishness, the temperature in such cases not unfrequently rising to 103° or 104°, with perhaps violent abdominal pain; and these symptoms may be sufficiently severe to excite alarm. If vomiting occurs relief is at once experienced, but more commonly purgation is excited, and may perhaps have existed for a few days before you are called in to see the patient. You must not expect the diarrhoea to cease until the whole of the irritating matter which excited it has been removed, and the sooner this result can be effected the sooner will relief be afforded. All the particles of half-masticated apples containing immature acids and other irritating organic compounds must be removed from the alimentary canal before the diarrhoea will cease. In such cases, therefore, it is bad practice to attempt to check the diarrhoea unless you feel sure that the whole of the irritating substances have been entirely got rid of. It is even desirable to encourage for a time the flow of fluid from the intestinal canal, so that the noxious matters may be thoroughly washed away. For this reason you will often have to administer a mild purgative to expedite the removal of the matter which excited the purgation. You purge to stop purgative action, and you will often find this the best and shortest method of checking the diarrhoea of children. Of all the purgatives that are known to remove irritating matters from the intestinal canal, oily purgatives are the most suitable. Common Olive-oil, Oleum Oliva, will act in this way, and for very young children is quite sufficient, but as a general rule you will find it expedient to give Castor-oil, Oleum Ricini, the purgative action of which is more decided. There is an active principle in the Castor-oil which affects the action of the stomach as well as the glands and vessels of the upper part of the alimentary canal. In this way, Castor-oil in its action contrasts with Aloes, Colocynth, and Sulphate of Magnesia, which act mainly upon the lower part of the small intestines and the colon. I suppose Castor-oil excites increased secretion in the stomach, the duodenum, the jejunum, and ileum, causing a quantity of fluid to be quickly poured out from the vessels and glands of the mucous membrane. Thus the alimentary canal is thor

CASTOR-OIL IN DIARRHEA.

147

oughly flushed in every part; and the action takes place from above downwards. Any irritating matters that may be present are thus swept away. For this reason, and for the further reason that Castor-oil is a substance which does not irritate the mucous membrane in any undue or uncomfortable way, it is the best purgative to give in any cases in which you have reason to attribute the diarrhoea to injudicious eating. Particularly in the diarrhoea of infants and young children is Olive-oil or Castor-oil a safe remedy. As a general rule, you will find a much smaller dose of Castor-oil will act than is usually administered. To a child of ten years old you may give half a teaspoonful or a teaspoonful; to an adult, two teaspoonfuls, but a single teaspoonful of Castor-oil will be sufficient for many people. The objection to Castor-oil is its nauseating, disagreeable flavor. I have already referred to the best way of taking it, and have offered some suggestions for disguising the taste. See p. 135.

After diarrhoea has continued for some time, there may be a good deal of severe griping pain all over the stomach, or at least in its upper part. At the same time the patient feels chilly or very cold, and may actually shiver; very generally there is more or less flatulence, with acid eructations, loss of appetite, and occasionally distressing nausea. The tongue is usually furred, and there may be a nasty taste in the mouth, or the mouth may feel clammy and disagreeable. After diarrhoea has lasted for several days, there may be considerable depression of the heart's action; and not unfrequently severe cramp in various muscles increase the distress.

Acid eructations and the rising of acid fluid into the mouth will be relieved by the administration of alkalies and other so-called antacid remedies. You may give alkalies, such as Potash, Liquor Potassa, twenty drops in a wineglass full of water once in three or four hours, or the Bicarbonate of Potash or Soda. Preparations of Bismuth are also useful, as the Carbonate of Bismuth (Bismuthi Carbonas), or the Nitrate, the old Trisnitrate of Bismuth (Bismuthi Nitras), from ten to twenty grains for a dose, suspended in water with the help of a little mucilage, or, better, prepared chalk (Creta præparata), or precipitated chalk (Calcis Carbonas precipitata). But one of the best as well as simplest remedies to give in these cases, and particularly in gastric and intestinal derangements occurring in infants and very young children, is Lime Water (Liquor Calcis). This is an extremely valuable remedy, which is not used as much as it deserves to be. Infants are very subject to diarrhea, and I fear that many a child has been lost simply from allowing diarrhoea to continue, which would have been easily checked, if sufficiently early in the attack a few teaspoonful doses of Lime Water in milk, or sweetened Lime Water (Liquor Calcis Saccharatus), had been given. Anything of an irritating character will very soon disorder the delicate mucous membrane of the intestinal canal of an infant, and a very simple remedy administered at the proper time will stop it, but if the purging

148

TREATMENT OF DIARRHEA.

be severe, and it be allowed to continue for a few hours, extreme exhaustion may ensue, and be soon followed by death. In these cases, mothers often make the unfortunate mistake of feeding the child too much. Fearing lest it should be starved, they keep pouring in milk. The secretions, already out of order, get worse, and the milk, instead of being properly digested and assimilated, is either rejected in the form of curd, or the curd formed is passed onwards into the small intestine, where it excites irritation without being taken up and absorbed. Coagulation of the caseine, without subsequent solution, may persist perhaps for many days, sometimes for a week or more, each new portion of milk that is swallowed undergoing the same change. Thus the intestinal canal, in every part of its course, becomes filled with firm white coagula, which, it will be noticed, constitute the greater part of every evacuation. After death from violent diarrhoea it is not uncommon to find the intestines even distended with coagulated and undigested curd.

Cases of diarrhoea in infants may often be relieved at the outset by small doses of Lime Water. A little may be mixed with the milk, in the proportion of a tablespoonful or less of lime water to half a pint of milk. Sometimes Potash Water answers better, and I have used Liquor Potassæ, in the proportion of twenty drops to half a pint of milk. You must not allow the child to take as much milk as it likes. For a day or two, half a pint of milk in the twenty-four hours will be sufficient. It must be obvious that, as long as the disturbed state of the bowels continues, it will be worse than useless to push food. Time must be allowed for the alimentary canal to become partially emptied of its irritating contents before fresh nourishment is introduced. If the child is at all low, it must be supported with small doses of brandy-from ten to twenty drops in a teaspoonful of water or milk and a little sugar, once in two hours. You cannot be too careful in watching cases of infantile diarrhoea, especially in weak children, for it sometimes happens that serious exhaustion comes on quite unexpectedly, and if you do not visit the patient every few hours, a sudden change may occur, and the case be hopeless before you come to its assistance.

I have already drawn your attention to the fact that in these cases of diarrhoea, bacteria often grow and multiply to an enormous extent in the caseine clots. In many cases every part of the intestinal canal is pervaded by millions of these organisms, which grow and multiply in the altered secretions and food which are continually being poured into the stomach. The changes which ought to take place in the food prior to its absorption and conversion into healthy blood are consequently prevented. Children may, under these circumstances, die of inanition, although they have been but too liberally fed during the whole period of the illness. The food they are plied with merely serves to encourage the growth of bacteria, and it actually undergoes changes which interfere with its digestion and absorption. If just at the right time you withhold