AS THE STOMACH CHURNS: A GUIDE TO THE RUNS
by Buck Tilton

Darkness approached and a chill February wind gnawed at the tent like a mad dog. Outside, the gurgle of the Ocklawaha River was drowned out by the rustle of oaks and palmettos, wind and water only a minor auditory disturbance compared to the bestial gnawing going on behind my belly button. In an attempt to limit exposure of my bare bottom to the angry storm, I had pre-dug half a dozen catholes within dashing distance. Over and over, throughout the long night, the same scenario was repeated: out of the bag, out of the tent, rush, squat, rush back. "Everyone can master a grief," wrote Shakespeare, "but he that has it."

The modern word "diarrhea" resembles the old Greek expression for "a flowing through." Ancient Egyptian doctors left descriptions of the suffering of Pharaohs scratched on papyrus even before Hippocrates, the old Greek, gave it a name few people can spell correctly. An equal opportunity affliction, diarrhea has laid low kings and common men, women, and children for at least as long as historians have recorded such fascinating trivia. It almost wiped out more soldiers in America's Civil War than guns and swords. In the developing world today, acute diarrhea strikes more than one billion human beings every year, and leaves more than five million dead, usually the very young. Diarrhea remains one of the two most common medical complaints of humanity.

"Frequent passage of unformed watery bowel movements," as described by Taber's Cyclopedic Medical Dictionary, diarrhea falls into two broad types: invasive and non-invasive. From bacterial sources, invasive diarrhea, sometimes called "dysentery," attacks the lower intestinal wall causing inflammation, abscesses, and ulcers that may lead to mucus and blood (often "black blood" from the action of digestive juices) in the stools, high fever, "stomach" cramps from the depths of hell, and significant amounts of body fluid rushing from the patient's nether region. Serious debilitation, even death, can occur from the resulting dehydration and from the spread of the bacteria to other parts of the body. Non-invasive diarrhea grows from colonies of microscopic evil-doers that set up housekeeping on, but do not invade, intestinal walls. Toxins released by the colonies cause cramps, nausea, vomiting, and massive gushes of fluid from the patient's lower intestinal tract. Non-invasive diarrhea carries a high risk for dehydration.

THE LIFE AND TIMES OF SEVERAL GERMS
I'll never know what caused the Agony Of The Ocklawaha. Diarrheal illnesses come and go with the vagaries of what one voluntarily and involuntarily ingests; erupt from numerous sources that include bacteria, viruses, and protozoas; last as briefly as a relatively blessed six hours or as long as a destructive three weeks or more; and strike more fear into the loins of some paddlers – especially third world visitors – than shoulder dislocations, elbow tendinitis, and strainers combined.

Escherichia coli, bacteria of which there are hundreds of strains – most of them living normal lives in the human gut, has a few rogue types that can cause invasive or non-invasive diarrhea. E. coli, as a source of non-invasive diarrhea, typically gets swallowed in water, fresh or salt, and produces headache and nausea along with stinky, watery stools in as little as a few hours after ingestion. In one to three days, the sorrow ends. Invasive strains, ingested from water or food, can cause severe dysentery.

Campylobacter, another bacterium, lives in the intestines of many wild and domestic animals and ends up in plenty of wilderness lakes and waterways. Campylobacter can also thrive in spoiled food, and gets credit for infecting as much as one percent of the U. S. population every year. After an incubation period of four to seven days, infection brings on general discomfort, fever, cramps, and bloody diarrhea that lasts two to seven days, most often sending the sufferer in search of a doctor.

Salmonella, bacteria with more than 2,000 types including S. typhosa, the source of typhoid fever, brings on an estimated 2.5 million cases of diarrhea a year in the United States alone. Almost every case arises from contaminated food (especially dairy products, poultry, meat, and eggs) or from a nontyphoid Salmonella that causes headache, fever, nausea, cramps, and, of course, the squirts. Symptoms show up 12 to 24 hours after ingestion of the germs. Within a few days, the symptoms usually go away.

Shigella, a bacterium responsible for the most dysentery, spreads, as most diarrhea-causing agents do, by fecal-oral contamination. You swallow the germs by drinking or even swimming in and accidentally ingesting infested water. One to seven days later the illness manifests itself. Fortunately, most sick people get better after a mild case of cramps and watery stools. But Shigella can cause severe dysentery, as well.

Norwalk virus, non-invasive, causes more food-related diarrhea than any other viral source. It spreads easily from one person to another. Though it may last a week, the vomiting and diarrhea this Norwalk virus brings rarely require a physician's care.

Giardia lamblia, a protozoa, heads the list of water-borne germs that cause "the runs." After ingesting the little bugs, it takes one to three weeks (the average is nine days) before symptoms show up. These symptoms are among the most unpleasant of non-invasive diarrheas: loose and foul-smelling stools, cramps, rotten-egg burps, loss of energy, loss of appetite, loss of weight, and loss of people who once enjoyed your company. Antibiotic treatment is often required.

Cryptosporidium, another protozoa, infects a large number of animals who then leave reminders of their passing in wilderness water. Cramps, nausea, gas, and diarrhea typically cause the patient distress for about a week. In immunocompromised patients, diarrhea has extended into years and has caused death.

"Traveler's diarrhea," to note in passing, is not a specific disease, but a syndrome. Although E. coli gets the nod as the cause of the largest number of traveler's diarrheas, many of the water- or food-borne germs may be the source.

UP CLOSE AND PERSONAL
Whatever the causative agent, a diarrheal illness can be mild, moderate, or severe depending on the frequency of the rush to the bushes, the pain of cramping, the wateriness of the bowel movement, and the vileness of the gas (the latter often being a matter of personal opinion). All cases, however, have in common the departure of water from humanity's hindmost orifice – sometimes oceans of fluid, up to 25 liters in 24 hours in the most severe cases. And it's not just water your body spills onto the ground. An impressive amount of electrolytes (potassium and sodium) can be lost during an episode of diarrhea.

Initially, the field management of all diarrheal illnesses looks the same: replace the lost water. Clear liquids are the best choice, liquids such as plain water, broths, herbal teas, fruit juices you can see through. If the illness continues and dehydration threatens, the patient will grow weaker with bouts of lightheadedness and dizziness, and he or she will require additional electrolytes. You can pack Oral Rehydration Salts in your first aid kit, or whip up a mixture in your water bottle. To one liter of water add one teaspoon of salt and eight teaspoons of sugar. If you've got baking soda, throw in a pinch, but you can get by without it. Mix well. Approximately one-third of the solution should be taken every hour along with all the plain water one can manage to get down. Look for clear urine, the most reliable field sign of a well hydrated person.

Pepto-Bismol not only relieves some of the torture of diarrhea, but also, according to controlled studies, provides reasonable protection against traveler's diarrhea. Imodium, another and stronger over-the-counter drug, reduces the cramps of diarrhea, and the frequency and volume of stools. With a prescription, Lomotil probably ranks as most seen at the scene of diarrhea. Beware: anti-diarrheal drugs should not be used if you think you have dysentery. Severe diarrhea, bloody stools, high fever, and tenacious vomiting are indications of something inside you that your body eagerly wants to get out. In case of dysentery, you should not be stopping the flow; you should be looking for a physician.

In the patient's best interest, stick to liquids for persistent and voluminous diarrhea. If and when the problem subsides in the field, provide bland foods such as bread, crackers, cereals, rice, potatoes, lentils, pasta, and bananas. Avoid alcohol, caffeine, spices, fruits, hard cheeses, and other fat-laden foods.

KEEP THE CRAMPS OUT OF CAMP
Water-borne agents account for the most diarrheas contracted on waterways that attract paddlers, and many of those germs are deposited by wildlife. Humans, however, are increasingly responsible for making other humans sick with the germs they carry, either in their bodies or in their food. Proven water disinfection techniques along with proper wilderness sanitation practices will prevent almost all diarrheal illnesses. Proper camp hygiene will stop most diarrhea-causing germs from getting an intestinal handhold.

1. Disinfect all drinking water via boiling, filtration, or halogenation. Boiling is the safest, and water needs only to reach the boiling point to be safe. Filtration works when the filter has been proven to keep out all the things you want kept out. The best filters remove protozoa and bacteria, and kill viruses with a special resin coating the filter. Halogens (iodine and chlorine) are the least best bet due to the variable results based on the concentration of the halogen, contact time with the germs, the clarity of the water, the temperature of the water, and the questionable efficacy of iodine and chlorine against Giardia and Cryptosporidium, especially in their cyst forms. To save money (but adding time to water disinfection), you can purchase a less-than-best filter and use it after halogenation to get out the resistant bugs.

2. Carry and properly prepare foods that last a long time before spoilage. Do not eat leftovers. Bacteria that may grow in leftovers will be killed by re-heating, but the toxins produced by the bacteria are virtually unaffected by heat.

3. Wash hands after a bowel movement and before preparing food. Use water and soap for hand washing, include the tips of your fingers, and dry your hands after washing.

4. Keep everyone even remotely suggestive of illness out of the "kitchen."

5. Do not share bandannas, cups, water bottles, eating utensils, etc.

6. Wash and dry all community cook gear after use.

7. Properly dispose of human wastes at least 200 feet from the nearest water source.

SIDEBAR: IF AND WHEN DIARRHEA
You never know when some microscopic diarrhea-causing nasty thing will slip through your defenses and into your intestinal tract to create trouble. To best deal with the situation:

1. Carry anti-diarrheal drugs in your first aid kit: Pepto-Bismol (bismuth subsalicylate) for minor cases, and Imodium (loperamide) for more serious problems. Neither of these drugs should be given to children without first consulting a physician.

2. Carry an emergency supply of toilet paper. Whatever your feelings about TP, you'll be happier if you have a stash hidden away when diarrhea strikes.

3. Bury the bowel movement at least 200 feet (about 70 adult paces) from a water source in a cathole approximately four to eight inches deep in organic soil. Cover the matter with soil, and hide evidence of the hole.

4. Wash your hands after each event.

5. Don't go swimming.

6. Don't help prepare food.

7. Don't reach into the gorp bag, share your personal eating, or drinking gear.