Sunday, September 29, 2013

IBD in the Age of Cholera

Historical Treatment of IBD:  The Early Years

Crohn’s disease and Ulcerative Colitis have a long history.  The first discovery of thickening of the terminal ileum was recorded in 1761 by Morganini.  Unfortunately, most of the earlier observation of ileocolonic inflammation was post-mortem, greatly limiting the treatment options.  Most early sufferers of inflammatory bowel disease were thought to have other more common conditions, such as consumption (now known as tuberculosis), cholera, or chronic dysentery.(1)  Treatment options were limited to hydration and herbal options that were region-specific.  An example of early treatment options for treating colitis (with apparently a “kitchen sink” approach) is mentioned in the 1872 book “The Complete Herbalist”:

A free lobelia emetic may be given at the outset, and the bowels evacuated by a purge; castor-oil with laudanum is the best for this purpose. After the purge, take twenty grains of quinine and one drachm of leptandrin, divide into six powders and take one every hour until all are taken. The tenesmus should be relieved by injecting into the rectum five or six ounces of starch water, containing about twenty drops of laudanum, as often as is necessary. Ipecacuanha is a superior remedy. Gelsemium may be given afterwards, and if required the fever should be controlled by veratrum. The patient should lie quietly in bed, and his diet should consist of grapes, baked apples, flour porridge, bread, rice, coffee, beef-tea and ripe fruit. The astringents are of course necessary, and for this purpose tannic and gallic acids kino, rhatany, opium, capsicum, cranesbill, etc., can be given. Tonics should be combined when the patient is weak, and if the debility is very great the alcoholic stimulants should be administered. I can with safety recommend my "Restorative Assimilant" as a sure cure for both acute and chronic dysentery, as well as for all bowel complaints. The Herbal Ointment should be rubbed externally on the whole abdomen to relieve the inflammtion. In the chronic form, the astringents, with such other remedies as may be indicated by the symptoms, are all that is necessary.

While dismissed today as mostly bunk, there is some science behind a few of the recommended treatments above:

Lobelia Emetic:  The subspecies of lobelia known as “Indian Tobacco” was used extensively to treat many conditions by the induction of vomiting.  Unfortunately, given the dehydration that comes with chronic colitis, this was more likely to kill a patient than to cure her.(2)

Castor Oil:  The turn-of-the-century cure all (the 20th century, that is), castor oil and its derivatives are still used as laxatives and as medicinal delivery additives.  Unfortunately, the laxative effect would only exacerbate dehydration, and potentially cause further mucosal damage.(3)

Laudanum:  Also known as opium, this one would have had an actual short term effect.  Opiates are well known for decreasing bowel motility, and can reduce the effects of diarrhea.  While opium itself isn’t frequently used anymore (given the side effects), other opiates are still commonly used (that Immodium in your cabinet qualifies) to treat short term diarrhea.  The direct injection into the rectum may have had a more immediate effect.(4)

Quinine.  Not specific to colitis, but more relevant for malaria treatment, quinine is one of the earliest known medicines still in common use (though there are more effective anti-malarials).  If the patient had recently come from the tropics, this may have helped the underlying malaria if present, but not necessarily done anything for underlying Crohn’s or Ulcerative Colitis.(5)

Leptandrin.  There is no specific definition of what leptandrin was – it included plants such as veronicastrum virginicum (leptandra).  There is no proven efficacy for leptandra, but it still continues to be touted by homeopaths and others and is a frequent component of non-proven hemorrhoidal compounds.(6)

Ipecacuanha.  Carapichea ipecacuanha is still used in medicine as a strong emetic.  Poison control centers will recommend using Syrup of Ipecac in specific ingestion cases because of its immediate and strong effects.  As with lobelia, inducing vomiting to treat a disease that causes dehydration is strongly contra-indicated today.(7)

Gelsemium.  Lost in the annals of history as a potential anti-malarial treatment, there isn’t much in modern literature proposing this as a treatment for IBD, but there is some current research showing efficacy in animal models as an anti-anxiety drug.  The potential calming effect may have been present in the earlier treatments, allowing the patient to be less stressed about their condition.(8) 

Veratrum.  A fairly toxic plant that was originally used to treat high blood pressure, veratrum has fallen out of favor in light of more effective drugs.  A derivative, however, is still used as a treatment for certain cancers – cyclopamine (named for the birth defect from ingestion of veratrum that can cause single-eyed offspring).(9)

Grapes, baked apples, flour porridge, bread, rice, coffee, beef-tea and ripe fruit.  There is some vestige of this treatment modality present in the current (though controversial in efficacy) BRAT diet.(10)  The concept of having fairly easy to tolerate foods with any type of stomach upset is easily understandable, (though how easily tolerated grapes are compared to other foods is questionable).

Tannic Acid.  The use of tannic acid at the time would likely have been a misuse related to tea.  Teas contain tannin (not tannic acid), and are the subject of a full post.  Various tannates (e.g. albumin tannate) are anti-diarrheals and this would have had a possible positive effect.

Gallic Acid.  Similar to tannic acid (and also found in tea leaves), gallic acid is a long used astringent.  There is little evidence of efficacy in colitis, but there is some preliminary data that showed some efficacy in treating NSAID-induced gastropathy.(11)

Kino and Rhatany.  These are both herbs that contain tannin compounds – see tannic acid above.

Opium.  See laudanum above.

Capsicum.  Capsicum plants are part of the nightshade family and include many peppers.  The ingestion of associated capsaicin would have negative short term effects on any active colitis, but there is some preliminary evidence that there may be long term positive effects (

Cranesbill.  Also known as germaniums, cranesbill hasn’t had any evidence of efficacy in modern medicine.  They do make a very nice addition to any garden as a robust, flowering plant that is fairly hardy and comes in a multitude of colors.

Alcoholic Stimulants.  Alcohol use and any form of colitis is contraindicated.  A large enough dose may have taken the person’s mind off their colitis, but the dehydrating effects would not have been welcome.  As with tea, alcohol warrants its own posting.

Restorative Assimilant.  Unfortunately, this is too reminiscent of recent offerings.  The author touts his own cure-all for treating colitis, and like so many other cure-alls over the years this one didn’t pan out.  This should hopefully be a lesson for those viewing ads that claim to cure any disease, small or large, with one simple solution…

This historical view of treating colitis is interesting and informative.  While taking all of the items recommended by “The Complete Herbalist” is likely to end up with a person becoming much sicker than when they started, some of the components that had a basis in observational medicine, the predecessor (but not a replacement for) science-based medicine, produced derivatives with efficacy in treating some of the symptoms of IBD.  Additionally, the shotgun-based approach of all of the above drugs could cause untold interactions – a cautionary tale for modern medicine.  The next post will look at the advancements in treatment of inflammatory bowel disease in the following century, through the present day.

Bottom Line

·         Some of the treatments in the 1800s have modern derivatives that are still used to treat disease.
·         Though some of the cures had a basis in observational medicine, many were still based in tradition and superstition – something that evidence based medicine still fights.

1.       Schofield, Philip F. "The Natural History and Treatment of Crohn's Disease: Hunterian Lecture delivered at the Royal College of Surgeons of England on 11th November 1964." Annals of the Royal College of Surgeons of England 36, no. 5 (1965): 258.
2.       Laffan, Robert J., and Herbert L. Borison. "Emetic action of nicotine and lobeline." Journal of Pharmacology and Experimental Therapeutics 121, no. 4 (1957): 468-476.
3.       Capasso, Francesco, Nicola Mascolo, Angelo A. Izzo, and Timothy S. Gaginella. "Dissociation of castor oilinduced diarrhoea and intestinal mucosal injury in rat: effect of NGnitroLarginine methyl ester." British journal of pharmacology 113, no. 4 (1994): 1127-1130.
4.       Machella, Thomas E. "The Medical Management of Chronic Idiopathic Ulcerative Colitis." Annals of the New York Academy of Sciences 58, no. 4 (1954): 499-502.
5.       Achan, Jane, Ambrose O. Talisuna, Annette Erhart, Adoke Yeka, James K. Tibenderana, Frederick N. Baliraine, Philip J. Rosenthal, and Umberto D’Alessandro. "Quinine, an old anti-malarial drug in a modern world: role in the treatment of malaria." Malar J 10, no. 144 (2011): 1475-2875.
6.       Boskowitz, George W. Extracts from lectures on therapeutics. Printed by courtesy of FA Greene, 1910.
7.       Magnani, Paolo, Anita Conforti, Elisabetta Zanolin, Marta Marzotto, and Paolo Bellavite. "Dose-effect study of Gelsemium sempervirens in high dilutions on anxiety-related responses in mice." Psychopharmacology 210, no. 4 (2010): 533-545.
8.       Magnani, Paolo, Anita Conforti, Elisabetta Zanolin, Marta Marzotto, and Paolo Bellavite. "Dose-effect study of Gelsemium sempervirens in high dilutions on anxiety-related responses in mice." Psychopharmacology 210, no. 4 (2010): 533-545.
9.       Taipale, Jussi, James K. Chen, Michael K. Cooper, Baolin Wang, Randall K. Mann, Ljiljana Milenkovic, Matthew P. Scott, and Philip A. Beachy. "Effects of oncogenic mutations in Smoothened and Patched can be reversed by cyclopamine." Nature 406, no. 6799 (2000): 1005-1009.

10.   Duro, Debora, and Christopher Duggan. "The BRAT Diet for Acute Diarrhea in Children: Should It Be Used?." Practical Gastroenterology 31, no. 6 (2007): 60.


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