ACUTE INTESTINAL DISEASES OF CHILDREN

The large infant mortality that results from intestinal diseases during the summer months is deserving of the most careful consideration, both of the physician and the parent.

Apart from the excessive heat of the summer, there is no doubt that an unfavorable environment, which means bad hygienic surroundings, bad sanitary conditions, bad food and home influences, contributes largely to the enormous number of these serious cases. Education, while it may be expected to influence favorably the sanitary and other conditions in the home, cannot change the home location. The child must continue to live in the same environment. It is in this cla.s.s of cases that these summer diseases are so very fatal. Children in better circ.u.mstances can take advantage of conditions which are denied to the tenement child. The diseases must therefore be faced and treated under these existing conditions.

In addition to the climate and the environment, there are certain factors that occur in all cla.s.ses which result in intestinal derangement. If the stomach or bowels are not performing their function properly, or if the food or method of feeding is wrong, these, plus very hot, humid weather, invariably result in serious intestinal disease. The mother must be taught to interpret properly the meaning of a green, loose stool in the summertime; she must appreciate that it is the danger signal and must be regarded seriously.

The very best preventive against summer diseases of the intestine is to guard particularly against any trouble with the child's stomach at all seasons of the year. A healthy stomach and bowel will resist disease, even in very hot weather.

The most important food product which has a direct relationship to this cla.s.s of diseases is milk. In a large city like New York it will remain impossible to solve the milk problem, despite the splendid efforts of the Health Department and the members of the medical profession, until the city itself shall establish milk depots and ice stations where safe milk, and ice to keep it safe, may be obtained at a nominal cost, or free, if the parents cannot afford to buy it. We, therefore, must recognize that the vast majority of children to-day are taking milk that is not suited to them, that is really not fit as a food for children.

The mothers do not know this and no steps are taken to render the milk more safe for them to feed to their children. These mothers are willing to do what is essential in the interest of their children, but they do not know what should be done. These people cannot afford a physician or a nurse to teach them, nor do they even know that their methods are wrong or that they need any instruction. We must carry the information and the explanation to them. We must show them the need for a change of methods. This is the work for those charitably disposed women who desire some worthy purpose in life, who really wish to do some real good. All the equipment they need is good common sense. They will tell these mothers why it is necessary to pasteurize the milk before feeding it to the baby. They will show how to keep the nursing bottles clean, and the nipples sweet and fresh. They will instruct them how to dress the baby in the hot weather and impress them with the need of giving it all the cool, fresh air possible. In short, they will gain the confidence and the good will of these mothers in a tactful and diplomatic way, and they will tell them all they know in language which they will understand regarding the care of the baby. In every city in the country this work is needed and is waiting for the missionaries who will volunteer. To teach mothers the need for boiled water as a necessary drink for baby and older children is alone a worthy avocation.

To impress upon one of these willing but ignorant mothers the absolute necessity for washing her hands before she prepares her baby's food, that she must keep a covered vessel in which the soiled napkins are placed until washed, that she should frequently sponge her baby in the hot weather, and explain thoroughly why these are important details, is a work of true religious charity. They should be specially taught to immediately discontinue milk at the first sign of intestinal trouble, to give a suitable dose of castor oil and to put the child on barley water as a food until the danger is pa.s.sed. They should be taught to know the significance of a green, watery stool, they should know that is the one danger signal in the summer time that no mother can ignore without wilfully risking the life of her baby. They should be taught to prepare special articles of diet when they are needed. If every mother were educated to the extent as indicated in the above outline the appalling infant mortality would fall into insignificance. It is not a difficult task nor would it take a long time to carry it out; it is the work for willing women who have time and who perhaps spend that time in less desirable but more dramatic ways.

It is the knowledge that aids in catching disease in its inception that counts. The worst infections begin as a mild condition and prompt treatment robs them of their sting. When treatment is delayed and the child is fed for twenty-four hours too long on milk, the condition which in the beginning could have been stopped promptly has developed and it becomes a fight for life.

It will be seen from the above that all we need is education.

Education of the mother primarily, but education of the missionary, the nurse, the physician, the munic.i.p.ality, and the State, each co-operating, each willing to work in the interest of a great cause, for the benefit of the human race and for the brotherhood of man.

ACUTE INTESTINAL INDIGESTION

Causes.--Overfeeding, unsuitable and improper food, irregular and indiscriminate feeding, sudden change from one food to another, as at weaning time, a change from a poor quality to a rich food, or vice versa. Conditions affecting the health of the child, especially the nervous system, such as hot weather, extreme cold, fatigue, or at the beginning of any of the acute diseases. Children sometimes are predisposed to attacks of intestinal indigestion; these children are delicate in health and have weak digestive ability. The slightest irregularity or error in diet will cause an attack in these children.

Symptoms.--The attack may come on suddenly or it may develop slowly.

The important const.i.tutional symptoms are fever, prostration, and a general nervous irritability. The child is seized with pain in the abdomen. The pain is referred to the region around the navel. It is sharp, colicky, and severe, causing the child to cry out and draw up its legs in an effort to lessen its severity. The child is exceedingly restless and acts as if it were on the verge of a dangerous illness. Gas in the bowel is not present as a rule as frequently as it is in infants under the same circ.u.mstances. In a few hours diarrhea sets in, the stools may number from four to twelve or more in twenty-four hours. The stools are acid, sour, and the odor may be very foul. They are thinner than usual and frothy from the presence of gas.

In very young infants suffering from a sudden attack of intestinal indigestion, the stomach, as well as the bowels, is invariably upset. If the indigestion is the result of a slower process, the stomach does not partic.i.p.ate in the process. The color of the stools in infancy is yellow, then yellowish-green, and later gra.s.s-green. Undigested food is always present and in infants the curdled casein of the milk appears as white specks or lumps in the movements.

The fever is high in the sudden cases and lower in the cases of gradual onset. The prostration is more severe when the onset is sudden and in infants may be very marked.

The termination of the disease depends upon the cause, the treatment, and the previous health of the child. In healthy children promptly and properly treated it may be all over in a week. In delicate, poorly nourished children, and especially in the summer time, it may be the beginning of trouble that may eventuate in death.

Treatment.--There is no condition in the whole realm of diseases of childhood where the knowledge of the mother may have such important results as this condition. The most effective time to treat these cases of intestinal indigestion is before the physician is called. There are few diseases in which time is so valuable, so far as final results are concerned, as it is here. Every mother should know the significance of a loose, green stool. She should be taught that it means danger and consequently demands prompt treatment. The first indication is to empty, thoroughly, the bowel. The best means for this purpose, if it is immediately procurable, is calomel. If calomel is not procurable at once give castor oil, two teaspoonfuls to an infant, one tablespoonful to an older child. Calomel should be given in one-eighth-grain doses, repeated every three-quarters of an hour for eight or twelve doses, until the bowel is thoroughly cleaned out. Don't be afraid of a few extra movements at the beginning. Better clean out thoroughly at the start than to be compelled to do it all over again after the child is weak and suffering from the poison of the disease. The next important thing to do is to stop milk at once. The thirst is usually intense and if vomiting is not present it can be moderately relieved by giving small quant.i.ties frequently of cool boiled water or mineral water or strained alb.u.men or barley water. We quite often have to stop all food and liquids by the mouth for twenty-four hours.

If the prostration is very great and the child looks as though it might collapse, it can be given brandy in cracked ice from time to time.

After the bowels have been thoroughly cleaned out, never before, some medicinal agent may be given to stop the unnecessary diarrhea. In a very large number of promptly and properly treated cases this is not needed.

If it is thought best to use it the physician will select the agent according to the conditions present and prescribe it.

Breast-fed infants rarely have intestinal diseases of a severe type. If they should develop diarrhea they must be taken off the mother's milk for twenty-four hours. They should be given a dose of castor oil or calomel and fed on barley water in the interval. The feedings should be reduced in quant.i.ty and the interval doubled. The two-hour interval will become a four-hour feeding: the three or four ounces at each feeding can be reduced to two ounces. The intention is to simply give as little as possible while the diarrhea is under way.

The mother's b.r.e.a.s.t.s must be pumped at the regular feeding time in order to preserve the flow, release the pressure, and keep the milk fresh.

It is sometimes a problem to renew feedings of milk without exciting a relapse of the diarrhea. It should not be tried until the stools are normal in color and consistency. This may not be for three or four days.

In resuming the milk it should be given in smaller amounts and diluted with lime water or barley water for the first day. Gruels may be given to which skimmed milk may be added: later add the ordinary milk. If it is well digested and does not cause any return of the diarrhea, the quant.i.ty of milk can be slowly increased until the former feedings are resumed. It is often of very great advantage to boil the milk for some time. Peptonized milk is safe and can be used in bottle-fed infants after diarrhea. In older children, meat, broths, eggs, boiled milk, and dry toast bread may be used sparingly for some time. Cereals, vegetables, fruits, should be withheld for a considerable time and watched carefully when resumed. k.u.myss, b.u.t.termilk, matzoon, bacillac, and other fermented milks are better borne than plain milk. All of these children need rest, fresh air, change of air, frequent bathing, and tonics, as an attack of this kind leaves them depressed, weak, languid, and anemic.

SUMMARY:--

1st. When a child complains of sharp, colicky, severe pains in the abdomen, around navel, which are shortly followed by foul, sour, frothy diarrhea,--greenish in color, it has acute intestinal indigestion.

2nd. Every mother should know that a green stool means danger. She should know to give at once a cathartic,--castor oil is good, but give a good large dose--then stop all food for twenty-four hours. If she learns this lesson she will have time to wait for the doctor; meantime, she may have saved her child's life.

CHILDREN WITH WHOM MILK DOES NOT AGREE

Contrary to the general belief, there are quite a large number of children in whom milk seems to act as a poison. These children are not necessarily constipated. They suffer, however, from a slow, continuous intestinal toxemia or poison. The symptoms of this condition are headache, disorders of speech, habitual sleep-talking, sleep-walking, and general nervous irritability without cause: they are listless, languid, and constantly tired. They may be bright in the morning and sleepy in the afternoon. They are irritable and cross and touchy.

Treatment.--Milk must be wholly discontinued. Eggs must be restricted to one every second day, and meat but once daily. The use of green vegetables is particularly suitable and should be given daily. Cereals and fruit also are good. Malted milk, k.u.myss, or matzoon may be given in place of milk. If constipation is present, rhubarb and soda mixture is an excellent laxative in these cases. A tonic should be prescribed for all these children.

DYSENTERY--ENTERITIS--ENTERO-COLITIS--INFLAMMATORY DIARRHEA

Cause.--Any cause which has been mentioned as a cause of ordinary diarrhea may result in this disease. It may occur at any time of the year and at any age. It may follow the infectious diseases. It may follow any other disease of the intestines.

Symptoms.--It may begin like an ordinary attack of acute intestinal indigestion. There is usually vomiting, fever, pain, and frequent yellow or green stools. The pa.s.sages may be blood-stained and there may be little or much mucus. The stools at the beginning have no odor as a rule. The bowels move very frequently, often with little or nothing to pa.s.s. There may be pain with each movement. The blood may disappear in a few days, but the mucus remains, often in large quant.i.ty in each stool.

At the beginning the fever is high, but it soon falls and remains low during the attack. The child loses weight, is irritable, has no appet.i.te, and looks and acts sick. When the attack is over these children do not gain their strength as readily as we would like; recovery is slow.

The acute symptoms usually last about one week, after this time the child begins to recover, but the process is a tedious one and one in which much care has to be exercised. It is an encouraging sign to note the disappearance of the blood in the stools and the return of the movements to the normal brown color. When these favorable signs are wanting the bowel is probably ulcerated and it will take a much longer time to return to normal and to be free from blood and mucus.

The above is the ordinary form of this disease and it ends in recovery as a rule. There is a more severe form, however, which differs from the above in the following way:

The fever is high and remains high; the stools are more frequent and there is more blood and more mucus in them; the child is much more irritable and is more profoundly sick. Death may occur at any time from the second day. If the little patient survives, the return to health is a very slow process; it often takes months and frequently years before a reasonable degree of strength is regained. Relapses are common, and they are very difficult to treat and care for. In some cases the child never wholly regains its former strength.

There are children who have been the victims of other intestinal diseases or conditions who develop colitis. The colitis in these cases may come on suddenly with vomiting and high fever, or it begins slowly, with no vomiting and with little fever. Their appet.i.te is poor, their digestion is feeble, their prostration is p.r.o.nounced. They lose flesh rapidly and may be emaciated to a remarkable degree. Very few of these cases recover completely. Serious and sometimes fatal relapses may take place. The feeding of these children is a difficult task and the greatest care must be constantly taken; a very little mistake may cost the life of the child.

Treatment.--All diseases of the intestine in childhood should be promptly and efficiently treated. If any form of diarrhea is neglected, it may result in the development of ileo-colitis with all its risks and uncertainty. When a child is seized with sudden bowel trouble, no matter what variety it is, it should be treated with the greatest care because "sudden" bowel trouble usually means plenty of trouble if it is neglected.

Fresh air is essential in all these cases. A change of air is of decided value as soon as the immediate symptoms have abated. The diet is the same as for children who have gastro-enteric intoxication. Later, much difficulty will be met because these patients have absolutely no appet.i.te,--peptonized skimmed milk is always good, beef broths are often well borne, liquid beef peptonoids may be tried. The food should be given every three hours. Boiled water and stimulants may be given between the feedings. Later in older children, raw beef, eggs, boiled milk, k.u.myss, or matzoon and gruels may be given. Great care has to be taken for months after an attack; relapses may be caused by changes of temperature, by fatigue, and, of course, by improper feeding. These children should avoid potatoes, tomatoes, fruits, corn, oatmeal, and a great many other things which an intelligent mother would not give any sick child, as candy, cakes, pastries, etc.

Cases which begin with free vomiting, thin stools; and fever should be treated at once. The bowels must be thoroughly cleaned out, the colon should be thoroughly irrigated, and all food should be stopped. When there are b.l.o.o.d.y stools with mucus and pain we must depend upon castor oil, irrigations of the colon, and opium and bis.m.u.th by the mouth. A good big dose of oil at the beginning is always necessary. If, however, the stomach is irritable and will not tolerate castor oil, we may subst.i.tute calomel in one-fourth-grain doses every hour for six doses, to be followed by citrate of magnesium. Irrigation of the colon in these cases is one of the essential means of successful treatment; it should be done twice a day during the first few days of the disease.

Stimulants are needed in all the cases. They help the heart, act as a food, and tend to quiet the general nervousness by favoring sleep. Good brandy given in boiled cool water is the best stimulant.

After the child is over the worst of the acute symptoms all medicine should be withdrawn and the proper kind of food given. Tonics will aid in restoring the strength. Cod Liver Oil during the following winter is a very good plan to aid in building up the vitality of the weakened bowel, but it must not be given too soon.

CHRONIC ILEO-COLITIS--CHRONIC COLITIS

Chronic Ileo-colitis fellows the acute variety. Cases which are unusually severe or which have been badly managed are likely to become chronic. A child suffering from this disease presents the following picture: The patient is emaciated, the abdomen is usually enlarged with gas, the feet are cold, the circulation of the blood is poor, the fever is low or absent altogether except when the child is having a relapse, when it jumps up suddenly. The bowels are loose and contain mucus, frequently in large quant.i.ties. The mucus may stop for a few days; then it appears again with a rise of temperature accompanied with loose stools with foul odor. These children are exceedingly nervous and irritable and are very poor sleepers.

Parents should be told it will be impossible to effect a rapid cure of these cases. It often takes months to get them started on the safe road.

The slightest mistake or change in the weather will upset the progress of the cure and it will be necessary to begin all over again. The entire hope of cure rests with the mother. She must be faithful, patient, and must carry out the physician's instructions implicitly. The management consists in diet, change of climate, and such other treatment as the physician finds necessary in each individual case.

Treatment.--In children under one year of age the only hope is breast milk, which must be given in small quant.i.ties. They do not do well on any starch food for a considerable period.

Where breast milk is not available the whites of two or three eggs may be given daily. They may be beaten up and given in skimmed milk, or in plain water with a little salt added. Zwieback or bread crumbs may be given in small quant.i.ties. They should be fed at four-hour intervals.