THE USE OF PEPSINE IN THE DIARRHEA OF INFANTS. BY JAMES S. HAWLEY, M.D., BROOKLYN, N. Y. THE USE OF PEPSINE IN THE DIARIilKEA OF INFANTS. In speaking of the causes of infantile diarrhoea, Dr. West, in his Treatise on the Diseases of Infants, makes the following remarks: "You will observe that the period of the greatest prevalence of diarrhoea coincides exactly with the time during which the process of dentition is going on most actively, and that more than half of all the cases of diarrhoea occur in children between the ages of six months and two years. "The older writers on medicine, whose notice this fact did not escape, attributed the disturbance of the bowels to a sort of sym- pathy between the intestinal canal and the gums, swollen and irri tated by the approach of the teeth to their surface. It must be borne in mind that there exists, during the period of teething, a more abiding cause, which strongly predisposes to its occurrence. All parts of the digestive canal, and of its dependencies, are under- going an active evolution to fit them for the proper assimilation of the varied food on which the young being will soon have to subsist. Just as the salivary glands are now being developed, and pour out saliva in abundance, so the whole glandular system of the intestines assumes a rapidity of growth and an activity of function, which, under the influence of comparatively slight exciting causes, may pass the just limits of health. In too many instances, causes fully adequate to excite diarrhoea are abundantly supplied in the ex- 4 cessive quantity or unsuitable quality of the food with which the infant is furnished ; lor it is forgotten that its condition is one of transition, in which something more than ordinary care is needed, while in accordance with that humoral pathology so popular among the vulgar, the profuse secretion from the irritated glands is re- garded as the result of a kind of safety-valve arrangeihent whereby nature seeks to moderate the constitutional excitement attendant upon teething." Here we have the fans et origo of infantile diarrhoea, an abiding, ever-present, predisposing cause, alwajs ready to be quickened into activity by innumerable excitants. Errors of diet or depressing and pamfui emotions, as anger, fear, grief or anxiety ; food, improper in quantity or quality; purturbing medicines and over-heating oc- cupations on the part of the mother, and similar errors of diet, changes of temperature and constitutional vices on the part of the infant, are ever ready and frequently occurring exciting causes. This condition of transition which the teething infant exhibits is everywhere impressed upon animated nature. In the human family we have not only the great transition state of the alimentary and digestive systems at the period of dentition, in which we are now more particularly interested, but later the state of transition which attends the lull development of the reproductive functions in which the nervous system is more particularly excited and liable to mal- development, and later still in life the second evolution in the generative system, when us functions, having fulfilled the order of nature, cease their activity. -Again the mental functions and sentient system are in jeopardy. '1 his danger to life and function which attends the great physical tiansitions in the human race, finds its counterpart in the inferior creation. In insect tribes, the various transformations from egg to larva, from larva to chrysalis, fiom chrysalis to the winged insect, are each and all attended by dangers and destruction of life. Each shedding of the shell of the Crustacea or skin of the reptile is a period of danger and frequently of death. Thus all nature speaks the same language and harmonizes with the teachings of science, that the periods of great change in the func- tions of the body are also periods of great danger. The proper functions of an organ, or system of organs, seem in whole or in part suspended or imperfectly performed during the period occupied by 5 organic evolution. Tn other words, while the organ, or system of organs, is being developed or modified in structure, natureffinds it necessary to rest from its labors, or materially diminish it activity. Tn the normal condition of the human body, the powers of nature are ample to carry on all necessary processes during the periods of evolution incident to the full development of the system. The vital machinery acquires sufficient momentum to carry its lagging and burdened wheels by the centres of obstruction which are met in each great developmental revolution. But in the artificial and mor- bid condition in which a large portion of infantile humanity is found, slight obstructions bring the machinery to a dead stand, or waste its powers in ineffectual attempts to continue its action. This, to continue the figure, is the moment when the engineer, by his lever, may complete the resolution, and again all goes for- ward in harmonious action. This is the critical moment when a grain of sand or a drop of oil may increase or diminish the friction, till on the one hand its motions may cease forever; or, on the other, pro- ceed with its revolutions till its destiny is fulfilled. Premising, then, that the great predisposing cause of infantile diarrhoea is the state of evolution which the digestive system and its dependencies are undergoing during the period of dentition, the question of therapeutics becomes one of comparative simplicity, and the evident duty of the physician is to allay that irritation of the organs which is exhibited in vomiting and purging,- first by the removal of all extraneous sources of disturbance, such as food, im- proper in quantity and quality, by protecting the skin from too sudden and frequent changes of temperature; secondly, by sedatives, to subdue the excitement which the foregoing causes may have in duced, and which, in the enfeebled condition produced by the transition state, are self-propagating; and, lastly, to impart to the struggling and overwhelmed digestive apparatus, that assistance which will enable it to convert food from the character of a foreign, and therefore irritant, material, into nutriment which will re-in- vigorate the natural forces, and enable them to accomplish success- fully the great and necessary evolution through which they are passing. Happily the practice of administering excitants to the already over-stimulated glandular system, has nearly passed away. Hydr. cretcR. and Hydr. chlor. are therapeutical formulae, seldom 6 penned, by one who opens his eyes to the light of physiological or rational therapeutics in infantile diarrhoea, As sedatives to the over excited mucous membrane and glandular system of the stomach and bowels, the preparations of opium and the salts of bismuth stand pre eminent. When irritation, without pain, exists, bismuth most promptly and satisfactorily allays it; but when accompanied with pain, the addition of a minute portion of opium becomes a necessary compliment to its effectiveness. We have now briefly noticed, in outline, the first two conditions of treatment, viz.: the removal of external causes of irritation, and the allaying of the morbid excitement which has sprung from their agency; and it may be asked if the natural functions will not now resume their offices, and the health of the patient be restored. Doubtless such would be the case did not lhe system labor under the combined effects of the transition state of dentition, and the im- pairment of strength due to the morbid causes above enumerated, and for which the correctives have been proposed. But the circle of remedies is not yet complete. The key-stone of the arch is want- ing, and, if left thus incomplete, will tumble back into the disorder and confusion from which it has been raised. The ingesta them- selves become, for want of digestive and assimilative power, irritants to the sensitive and debilitated organs. Instead of affording nutri- ment to fortify the system against the dangers of the crisis through which it is passing, the food going through the intestinal canal in an undigested form, becomes, itself, an irritant, and adds another mor- bid cause to those already existing. This is not all: the food does not always remain a simple, foreign substance, inducing irritation, but undergoes putrifactive decomposition, adding new and more active sources .of disease. Here, then, is the gap in which we are to stand. And what are the weapons we are to use? Tonics and stimulants, as indispensable as they often are, here become awkward and doubtful. They are indirect and secondary-whips to stimulate lagging energies, and not power to perform the labor and lift the bunden. Here the happy thought of Corvisart comes to our relief. The very function which is crippled, we can replace; the very strength which is ex- hausted, we can supply. By the administration of pepsine, we at once convert the ingesta into nutriment. They not only cease to 7 be irritants to the digestive organs, but are absorbed into the circu- lation, and becomes sources of power instead of weakness. Now we have fulfilled all the indications. First, to remove all sources of irritation from the quantity or quality of the ingesta, or change of temperature. Secondly, allaying irritation by sedatives, Thirdly, artificial digestion by the administration of pepsine. This simple but effective treatment is not new, but has more than once been presented to the profession for its approval. In support of its efficacy, especially that portion which relates to artificial digestion, and which this paper is particularly intended to illustrate, a few cases will be brought forward. The first case is one reported in the Revue Medico Ohir. de Paris, Dec., 1856. M. X , aged 4 years, was admitted into the Hospital of &. Eugenie on the 23d of November, 1854, under the care of M. Barthez. For many months this child had suffered from frequent diarrhoea, until it was emaciated and debilitated to the last degree. The appe- tite was voracious, and the stools contained much undigested food. In the first instance, M. Barthez tried the effect of properly adjusted diet, with small doses of trisnitrate of bismuth, but without avail. He then tried the pepsine, giving a dose (grs. 5) at the commence- ment of a meal composed of the ordinary food of the hospital. On the following day (the 1st of December) the stools were of a better color, and in other respects more natural than they had been before ; encouraged with this result, the same quantity of pepsine was ordered to be given before each meal. Dec. 3d. No stool. This was the first day without a motion for many months. Dec. 4th. Still no stool. The pepsine discontinued. Dec. 5th. Two somewhat fluid motions, although there was no change in the diet. There was, however, no undigested matter in the motions. The child was much better in every respect. Three weeks afterwards the child was discharged cured. M. Barthez, however, did not return to the pepsine, but contented him- self with small doses of the trisnitrate of bismuth. This case led M. Corvisart to try the effects of that remedy in the diarrhoea of very young infants. 2d Case. Alexander Lang, born on the 2d of August, 1855, was seized on the 25th of October, with diarrhoea, after a very obsti- 8 nate attack of erythema and eczema. This diarrhoea was accom- panied with frequent hiccough and vomiting. On the 3d of Novem- ber, 8 grs. of pepsine were given night and morning. On the 4th the same treatment was continued ; and now the vomiting and purg- ing have disappeared, the stools have become natural, the child takes the breast with avidity. The pepsine discontinued. Nov. 22d. The vomiting and purging have returned. M. Cor- visart has again had recourse to the pepsine. Nov. 23d. The vomiting and purging have ceased, and the stools are natural. From this time the little patient went on well. M. Corvisart adds, that many cases of the kind have failed under his notice, and that the acidified form of the pepsine, which he him- self tried, was quite as efficacious in these cases as the neutral form proved to be in the hands of M. Barthez. The writer has been in the habit of administering pepsine in the diarrhoea of hand-fed and teething infants for several years, with marked success. Notes of former cases not having been preserved, a fqw which have occurred in the last few days must suffice. Case 3. July 19th. Thomas Kennedy, aged 15 months, has had diarrhoea a week, is fed, passages watery and contain undi- gested food. R Am. Pulv. Pepsiue. Sub nit. bismuth, aa grs. 5 every 3 or 4 hours. This single prescription terminated the disease. Case 4. July 20. John Kneister, aged 18 months, is teething, diarrhoea has existed ten days, passages very watery and frequent, and contain undigested milk, R Am. Pepsine. Sub nit. bismuth, aa grs. 5 every 4 hous. This case was also relieved by a single prescription of ten powders. Case 5. August 2d. P. Quigley, aged 8 months, has had diarrhoea a week, and been treated by another physician by astrin- gents and opiates without benefit. 9 R Am. Pepsine. Sub nit. bismuth, aa 3 i in 10 powders, one to be given every 3 or 4 hours. This case also recovered completely under this single prescrip- tion. Case 6. August 5th. Mary Duryee, aged 11 months, has four incisors on each jaw, but no marked signs of the approach of other teeth. Has suffered considerable from diarrhoea for two weeks. On the 5th the diarrhoea increased alarmingly, accompanied by vo nit- ing and great prostration, as well as pain. The vomiting was allayed by liq. bismuth, and the following prescription made: R Am. Pepsine. Sub nit. bismuth, aa 3 i. Pulv. opii, gr. i, divided into 12 powders, and one given every 1 to 4 hours, accord- ing to circumstances. This treatment, with slight modifications, according to pain or frequency of the discharge, has been continued to the present time, (Aug. 10th) with nearly complete relief to all the symptoms, and she is now out of danger. Case 7. August 5th. Robert Kelly, aged 9 months, is teething, has had protracted diarrhoea and vomiting, is much emaciated, and passes large quantities of undigested milk, which are highly offen- sive. He has been for some time under treatment before coming to me. Pepsine and bismuth were prescribed in the usual manner, and continued three days, when the child died. It is to be noticed in this case that the coagulated milk disappeared from the stools on the second day, showing the efficiency of the pepsine. The only remaining case, to which I will allude, is one rather of infantile inanition than of true diarrhoea. Case 8. July 28th. D. N , an infant two weeks old, said to have been born in a plump and healthy condition. Its present state is one diametrically opposite. Its face is thin and skinny, exhibit- ing painfully the bony outline. It has thin, muddy, but not frequent alvine discharges, and vomits whatever it swallows, even to half a teaspoonful of its mother's milk. It lies stupid, with its eyes closed, and refuses the breast. It also has an intense muguet. In this ex- tremity I ordered three grains of pepsine to be given every three 10 hours, and half a teaspoonful of the mother's milk to be administered with great frequency. The following morning I found the mother, through utter hopelessness, had greatly neglected my directions. It was only through much persuasion, and the co operation of a friendly neighbour, that she was induced to pursue the treatment. During that day the vomiting ceased, and on the following day the child took the breast and retained and digested its nourishment. From this day it steadily improved in condition, and its diarrhoea and muguet disappeared. On the 8th inst., one week after my last visit, I was called to see its mother, and could hardly have recognized the infant which so lately had seemed in the last stage of inanition. Its face had ac- quired a comparative fulness, its color was restored, it nursed well and freely, and seemed as likely to live and thrive as any infant. This child was simply starving to death. What led to its condition of inanition I could not satisfactorily learn, but its state seemed most hopeless. This case illustrates, in a remarkable manner, how little assistance will restore the digestive faculty to its normal activity, and enable it to perform its functions unassisted. Case 9. Christian Schwindt, aged 2| years. This child has been suffering about six months from diarrhoea, and has become extremely emaciated and pallid. His food is passed undigested soon after ingestion. He has been under treatment dnring the greater part of his illnes, without success, and one of his medical attendants had pronounced the case incurable. I ordered 15 grs. of the z\m. Pepsine every time food was taken. The stools immediately began to show less undigested food, and the diarrhoea to abate. In four or five days the diarrhoea ceased, and flesh began to return to the emaciated frame. At the time of making this note, one month after the adminis- tration of the pepsine, he is in perfect health. Without adding cases of a similar kind from our own experience, which would, perhaps, extend the list to a tedious length, we take pleasure in submitting the testimony of Dr. R. E. Van Gieson, in favor of the efficacy of the preparation of pepsine in the diseases under consideration. The Doctor, in furniahing us with his notes, remarks: "I have found pepsine peculiarly fitted for the treatment 11 of that fearful scourge of children, cholera infantum, after the more profound and violent initial symptoms have been subdued by direct sedatives, such as hydrocyaic acid, ice, creosote, and the like. It has seemed to me that when the vomiting and purging have by such measures been arrested, that the whole gastro intestinal tract is utterly incapable of assimilating even the blandest articles of ali- ment. We stand, as it were, between the danger of starvation on the one hand, and the peril of again irritating the intestines to the evacuation of exhausting discharges by the administration of food. Just here pepsine is the remedy. By its aid we can secure the di- gestion of food which would otherwise irritate. So long as the stomach is disposed to remain quiet, we need not feel alarmed if for a day or two the discharges are somewhat frequent. An astringent and opiate suppository wiil control this, and, in the meanwhile, we are gradually bringing the intestinal tract to its normal condition, i. e., digestion. " Another great advantage arising from the use of pepsine in this disease, has been rendered aj parent by a careful comparison of cases treated by the most approved method in vogue some eight years ago. The medical gamut was then sedatives, opiates, astrin- gents, tonics. It yielded good results, but the cases were a long time in getting well. There came a period when the pernitrate of iron and the salts of quinia seemed almost powerless. This might be the third week or the third month in the disease. There was no par- ticular irritation of the stomach, but unless the astringent was given with great regularity and in augmented doses, the discharges still continued. In these protracted cases the gastro-intestinal system seems but a passive tube, through which the food passes pretty much as it entered the mouth, giving but little nourishment to the patient and much annoyance to the atonized viscera. In these cases pepsine is very clearly indicated, and will slowly, but quite certainly, aid in the digestion of judiciously selected nutriment, until the system can recuperate sufficiently to manufacture its own pepsine, when the artificial substitute can be withdrawn. The annexed case illustrates the foregoing remark in a very clear manner. C. H , aged 13 months, hand fed, chiefly on condensed milk for last ten months ; central and lateral incisors through ; first came 12 under my care July 29th. Past history : Has been under treatment by another physician for a week. Was taken in the beginning with vomiting and purging, which were in a measure subdued by the treatment. The child was then pronounced better, and the visits discontinued. Present condition : The child is much emaciated, face shrunken, and of that senile appearance so indicati ve of the ravages of cholera infantum. The stomach is still irritable, and the bowels operate from 5 to 8 times in twenty-four hours. Discharges similar to chopped spinage. The child craves drink constantly. Il pepsine, 3 i; make xii powders and give as before, wit plenty of open air. Under this treatment the child has steadily improved. The discharges are growing firmer in consistency each day, and vary in frequency from one to three in twenty-four hours. The appetite being now fair, and the discharges nearly normal, the pepsine will be withdrawn, and port wine and tincture cinchona substituted. The following cases, kindly furnished by my friend Dr. W. Fisk Sandford, comprise the entire number of cases treated by him, in the months of June and July, 1871, and exhibit very clearly the method of treatment of infantile diarrhoea, set forth in this brochure. Case 1. June 17th, 1871. Allen, baby, 9 months old. No teeth through. On mother's milk. Has had diarrhoea for two weeks. Mother has given it paregoric, &c., but he is worse. June 18th.. Has had 9 to 11 passages daily ; to-day they contain undigested food; are somewhat bloody in appearance. Il Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 i. Pulv. Opii gr. ss. M. et. pulv. ft. No. xii.; S one 4 times daily. June 18th. Baby better; no blood; Continue treatment. June 21st. Still better. Il Am: Pulv. Pepsine. Bismuthi Sub nit. aa 3 i- M. et pulv. ft. No. xii.; S one-fourth of a powder every three hours, before nursing. No further diarrhoea, during or after use of last prescription. Case 2. June 20th. Lizzie Webber, age 2 years, Dysentery. 9 Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 i. Pulv. Opii gr. i. M. et pulv. ft. No. xii.; S one every three hours. Well in two days. 13 Case 3. Hazzlebon, baby, 9 months old. Teething. On mother's healthy milk. June 20th. Severe diarrhoea for several days; growing worse; to-day vomiting, also. Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 i- Pulv. Opii gr. i. M. et pulv. ft. No. xii; S one every three hours. Next day baby was much better, and in three days well. Case 4. July 1st. Brush, 18 months old. Severe Diarrhoea. 3 Pulv. Opii gr. i. Bismuthi Sub nit. 3 i. M. et pulv. f. No. xii; S one every three hours. July 2,d. No. better. Continue previous prescription. July 3d. No better. 3, Am. Pulv. Pepsine 3 ss. Bismuthi Sub nit. 3 i- Pulv. Opii gr. ss. M. et pulv. ft. No. xiii.; S one with food every three hours. July 5th. Much better, and in two days well. Mother informed me three months later that the baby had had several attacks of diarrhoea since, but " a few of those last powders cured him without our needing to send for you." Case 5. Called July 2d, 9 a.m, Creighton, age 2 years. She has been vomiting and purging severely all night. Am. Pulv. Pepsine. Bismuthi Sub hit. aa 3 i. M. et pulv. ft. No. viii. ; S one every three hours, with beef tea. 3 p.m. Vomiting ceased, but much pain and diarrhoea. Added 1 gr. of ipecac, i gr. of opium to each powder, and ordered half one to be given every hour. 9 p.m. Better, but pain and frequent passages. Ordered 1 drop Tinct. Opii twice in night, and one-half powder every three hours. July 3d, 9 a.m. Better, only two passages in 16 hours. Con- tinue the first powder and give 1 drop of Tinct. Opii after each evacuation. July 4th. Quite smart, but diarrhoea still keeps up a little. Re- newed the first prescription ; had no need for any other medicine. Perfectly well in two days. 14 Case 6. Cooper, 15 months old. Diarrhoea for a week or more. July 3d it was worse. Offensive white discharges. Baby partly on mother's milk, partly on cow's milk. Teething. $ Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 ss. M. et pulv. ft. No. vi; S one powder every three hours, with, beef tea. July 4th. Much better; renewed powders; continued treat- ment for a few days; baby soon well. Case 7. Called July 5th. Lizzie Allen, age 9 months. On healthy mother's milk. Baby has had green passages and severe straining and vomiting for four days. No teeth through. 20 pass- ages a day, or more, very watery. Fever high. Il Pulv. Ipec. Comp. grs. vi. Bismuthi Sub nit. Pulv. Am. Pepsine aa 3 ss. M. et pulv. ft. No. xii; S one every three hours before nursing. July 6th. No better, excepting vomiting stopped. Il Tinct. Opii gtts. viii. Syr. Simp. 3 i. M. ; S half a tea- spoonful every 2 hours, alternating with one-half of yesterday's powders. July 7th. Much better. Continue one half a powder every two hours, a mixture after each passage. July 9th. Passages quite natural. Il Am. Pulv. Pepsine. Bismuthi Sub nit aa 3 ss. M. et pulv. ft. No. viii; S of powder before nursing. Soon well. One or two light returns, during the summer, which the pepsine and bismuth easily cured. uCase 8. Augustus T , one year old. Six teeth through. On mother's milk, in part, and cow's milk for six months past. 1 July 6th. 1 a.m. Has had profuse diarrhoea for several days. Paregoric has been tried, in vain. During the night has had much worse vomiting and purging. This morning vomits more seldom, but passages very frequent. li II Am. Pulv. Pepsine. Bismuth! Sub nit. aa 3 i. M. et pulv. ft. No. xii; S one with each feeding every three hours. 9 p.m. Much better; only three passages since morning. Con- tinue the powders. 15 July 7th. Almost well. Give one-half powder every feeding for two days. July 9th. Has had no further trouble. An attack a few weeks later, of diarrhoea, while baby was in the country, was easily cured by a box of " the powders," which the mother had taken with her, by my advice. Case 9. Miller, 7 months old. 2 teeth. On cow's milk. Severe diaarhoea. $ Bismuthi Sub nit. Am. Pulv. Pepsine aa 3 ss. M. et pulv. ft. No. viii; S one every three hours with feeding. Notes of this case are too long to arrange. Child grew slowly worse, under various treatments, and died in about three weeks. No other remedies seemed to have any good effect, and I returned to the above powder, which seemed to do better than anything else. Consultations were held, and suggestions of other physicians care- fully carried out, in vain. Case 10. July 11th. Charlie Rowley, 2 years 3 months old. Has had diarrhoea for several days. The passage examined was most extremely putrid in odor, end full of undigested food. $ Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 i- Pulv. Opii gr. ss. M. et Pulv. ft. No. vi; S one with each meal. July 12th. Better; continued the powders three days, when he was well. Case 11. Lockwood, 2 years old. Has had diarrhoea for some days. July 8th. I was called to see her in a convulsion. After com- ing out of which I ordered ]J Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 i. M. et pulv. ft. No. xii; S one with every meal about once in 4 hours. July 9th. Much better. July 11th. Well. Case 12. Called July 19th. Willie Nelson, six months old. Diarrhoea for several days. On mother's milk. 16 $ Am. Pulv. Pepsine. Bismuthi Sub nit. aa 3 ss. M. et pulv. ft. No. viii; S half powder before nursing. July 29th. Better; continued powders for 4 days. Cured with- out further trouble. Of course the writer does not intend to exhalt pepsine to the position of a specific in infantile diarrhoea. It is only claimed that its use is one step in the right direction ; that it is capable of remov- ing one of the principle predisposing causes, to wit: the impairment of the digestive function by the evolution which occurs at the period of dentition, and of preventing the irritation which attends the passage and decomposition of undigested food. A favorite observation of the writer is, to mark the gradual dis- appearance of undigested food and fetor from the evacuations, feel- ing assured that so much, at least, is well and in the right direction, whether the case proceeds favorably or not. . Many-other considera-* tions influence the course of the disease, and these indications must be met by their proper remedies, according to the judgment of the practitioner. I will close this hasty and imperfect paper by commending, pep- sine to a fair trial in the treatment of infantile diarrhsea, especially during the period of dentition. It has no noxious or perturbing qualities. It has physiological reasons in its favor, and has, to some extent, borne the test of experience.