CHAPTER VII DISEASES OF THE DIGESTIVE TRACT (Part 1)

CHAPTER VII DISEASES OF THE DIGESTIVE TRACT (Continued) Diseases of the Intestines The small intestine at birth is about 9 feet long, and the large intestine about 18 inches long. The lower half of this length is occupied by the sigmoid flexure. Feces. — The first stools after birth are called meconium. Four to six stools a day of this discharge are natural. By the fifth day the stools should assume the appearance of milk feces. Milk Feces. — The normal amount discharged by a healthy nursing infant is 2 or 3 ounces. They are soft, yellow, and of good consistency. Mother's milk and cows' milk give practically the same stool. The number of stools during the first two weeks is from three to six daily. After the first month two stools a day is the average. Symptoms. — The chief symptoms of any disease of the intestines are constipation, diarrhea, and tormina. When the rectum is the seat of the lesion we have added tenesmus. Constipation is an unnatural retention of fecal matter. Its symptoms are infrequent stools, dyspepsia, fetid breath, headache, vertigo, lassitude, and anemia. In aggravated cases we frequently find hemorrhoids, fissures, fistula?, and prolapse of the rectum accompanying these symptoms. In infancy ordinary constipation nearly always can be corrected by the proper milk mixture, increase in the fats 122 DISEASES OE CHILDREN FOR NURSES being all that is necessary. A soap-stick, some form of suppository, or introduction of the greased little finger act well in stubborn cases. At times enemas are neces- sary. These should not be used continuously. In older children ordinary constipation can usually be overcome by a regular time for defecation and systematic exercise; abdominal massage and electricity are valuable aids. Encourage the use of water, bran -bread, green vegetables, and stewed fruit. A glass of water before breakfast is often all that is required. Chronic Constipation. — As long as the child has the proper strength food for its age, constipation should not be troublesome. In artificially fed children, however, cases of chronic constipation are quite frequent. The nurse can correct this fault to a great extent by proper management of the case. In older children the most important measure is to establish a regular time for stool. After breakfast is the best hour. The diet should be mixed, starchy food re- stricted, and fruits encouraged. Meat and green vege- tables should be eaten at least once a day, oatmeal is the best cereal, and orange-juice and stewed prunes the best fruit. Massage should be practised twice a day, after retiring and in the morning. The proper method of giving massage is to use only the hand (without grease of any kind), rubbing the abdomen with a circular motion. The object is to move the skin and muscles upon the intestines, which starts peristalsis, the worm-like movements that force the feces along. Exercise is accomplished during playtime, and is usually sufficient. Suppositories are valuable at times to start the habit of defecation at a regular hour, but should not be continued longer than DISEASES OF THE DIGESTIVE TRACT 1 23 absolutely necessary. Gluten and glycerin suppositories are the best. If enemas are necessary, 1 dr. of glycerin to \ ounce of water is the best injection to use. At stool a low chair aids the child better than the high seat for adults. Diarrhea is a condition in which the stools are either too frequent or too loose. Like dyspepsia, it is a symptom of many pathologic conditions. Any condition which tends to lessen the peristalsis of the bowel will cause constipation; any condition which tends to irritate the mucous membrane of the bowel will usually cause diar- rhea. Tormina or intestinal colic is a painful, spasmodic affection of the intestines. It is generally the result of irritating food, flatulence, or fecal accumulation. It is characterized by paroxysms of severe pain of a twisting character centering around the umbilicus and relieved by pressure. The abdomen is usually distended. Severe attacks may lead to incipient collapse, indicated by cold sweats, pinched features, feeble pulse, and vomiting. The attacks often last from a few minutes to several hours, and generally end by a discharge of flatus. In severe attacks enemas, hot applications, aromatic spirits of ammonia, and paregoric are necessary. Tenesmus is a feeling of fulness in the rectum with a constant desire to defecate. MALFORMATIONS Congenital atresia 0} the anus is seen occasionally. It should always be looked for after birth. Through some fault of nature in these cases the rectum becomes con- stricted, or the skin covers its outlet. This prevents any 124 DISEASES OF CHILDREN FOR NURSES fecal passage. It results in death if prompt relief is not obtained. A baby that does not have a bowel movement in the first twenty-four or forty-eight hours should be examined immediately. DIARRHEA Diarrhea is an acute inflammation of the mucous mem- brane lining the intestines. It is the so-called intestinal catarrh. The different varieties of acute diarrhea are: mechanical, caused by foods which act as foreign bodies; drug, caused by any of the ordinary cathartics in suscep- tible children; acute intestinal indigestion; nervous diarrhea; and diarrhea of certain diseases like uremia. The best method to adopt in diarrhea caused by indiges- tible foods and indigestion is to give castor oil, followed by bismuth, and to restrict the diet. Acute Intestinal Indigestion. — In young children an acute attack of indigestion shows both gastric and intes- tinal symptoms; the intestinal symptoms, however, are always the more marked of the two. In older children intestinal indigestion alone is seen. The symptoms are colicky pain, distention, and diarrhea. The pain is localized in the stomach and around the umbilicus. About an hour or two after the onset of the attack diarrhea develops. From four to twelve stools are passed. They are greenish-yellow in infants, and contain undigested food. There is fever, ioo° F. to 102 ° F. The pulse is rapid and the features pale and pinched. Treatment. — Give castor oil and restrict the diet. In nursing babies give barley-water for twenty-four hours, and at the end of this time return to the breast. The feedings should be at six-hour intervals and the baby DISEASES OF THE DIGESTIVE TRACT 1 25 allowed to remain at the breast only for live minutes at a feeding. Barley-water is given in the interval. The diet of older children in the acute stage should be similar to that of an infant. Later, broths, eggs, milk, and dried bread or toast can be given. Fruit, vegetables, and cereals should be withheld for several days and then re- turned to slowly. Chronic Intestinal Indigestion. — In infants the symp- toms at times resemble marasmus. The symptoms most often seen are loss in weight, anemia, colicky pain, alter- nating diarrhea and constipation. The bowel movements are characteristic. If there is diarrhea the stools are greenish and often contain white curds. If constipated, the stools are often white. The child cries a great deal, is very restless, and sleeps poorly. Treatment. — It is in these cases that the proper modifica- tion of milk does so much good. In very stubborn cases buttermilk, properly prepared, seems to cure. The proper way to prepare buttermilk is as follows: Flour, 3I dr.; cane sugar, 15 dr.; buttermilk, 1 quart. Bring up to the boiling-point, stirring continuously. Then cool rapidly. While the percentage of proteids in this mixture is much higher than is usually given in such conditions, it is more easily and rapidly digested. Often the improvement is remarkable. Buttermilk should not be used for any length of time without the addition of cream. In older children, from four to seven years of age, the symptoms are as follows: The child is under-developed, pale, thin, and has a prominent abdomen. There are dark rings under the eyes, they easily tire, and are fretful and emotional. The stools are foul, there may be con- 126 DISEASES OF CHILDREN FOR NURSES stipation or diarrhea, and a great deal of gas. Such children frequently grind their teeth, giving rise to the supposition that they have worms. Convulsions are not uncommon. Treatment. — In such cases a trained nurse is invaluable. The chief thing to regulate is the diet. This should be placed entirely in her hands. It is a fact th?.t the princi- pal diet of children suffering with this condition usually consists of sugar, potatoes, and oatmeal. These should be interdicted, and for a beginning a diet of rare meat (scraped beefsteak or mutton), and milk instituted. Under the physician's orders, additions will be made, consisting of fruit, kumiss, stale bread, raw oysters, vegetables, etc. Potatoes and oatmeal should be for- bidden for some time in these cases. Proper clothing, cold sponging in the morning, open-air exercise, and cool sleeping-rooms are of equal importance. Summer Diarrhea. — When diarrhea attacks young children in the summer time, it is the so-called summer diarrhea of childhood. This is the most fatal disease of childhood. It occurs in epidemic form regularly every summer in most large cities. The changes in the bowel are slight, amounting in most cases only to a superficial catarrhal inflammation, often bearing no relation to the severity of the symptoms. These are mainly due to the absorption of toxic materials resulting from putrefactive changes in the stomach and intestines (Holt). The chief causes are warm weather, infancy, bad hygiene, and artificial feeding. The symptoms are frequent stools, three to twelve a day. They are of yellowish or greenish color and contain undigested food. There are colicky pains with rumbling DISEASES OF THE DIGESTIVE TRACT 1 27 noises (borborygmi), and slight fever with its attending phenomena. These symptoms usually follow an acute attack of indigestion and are accompanied by gastric symptoms which may set in at almost any time after its onset, the principal feature of which is the persistent vomiting. After a time the stools become offensive, mucus is present, the appetite may be normal, but is often impaired and may be almost lost. The tongue is coated, the mucous membrane of the mouth is congested, and in very young infants is often covered with thrush. The general health may not be noticeably affected for several days, but more often the infants become pale, their limbs grow soft and flabby, they lose their spirits, are fretful, sleep badly, and the scales show a decrease in weight of from one to two pounds a week. Treatment. — It is in these cases and also in those of marasmus that modified milk does so much good. Prophylaxis. — The infants' clothing should be light flannel; a single-piece dress is the best. Their napkins should be changed immediately after soiling. They should have fresh air, sunlight, and frequent bathings. Maternal nursing should be practised in every case where it is possible. Weaning should be avoided during the summer months. Overfeeding should be prohibited. Less food at a feeding by one-third, and more water, is a good rule to follow during the hot weather. Early attention should be given to all mild disorders of the gastro-intestinal tract. Finally, if artificial feeding is necessary, the proper modification of cows' milk should be used (see Chapter XVIII.) . If possible, children suffering from summer diarrhea should be sent to the seashore. They should not be 1 28 DISEASES OF CHILDREN FOR NURSES allowed to walk, but should lie out in the fresh air as much as possible. At the onset of an attack of diarrhea in summer give a dose of castor oil and starve the child for twenty- four hours. Barley-water may be used to allay the thirst. Nursing. — The nurse should be impressed with the fact that the diet is the important part of the treatment, and that the administration of foods requires as much care as that of drugs. At times in the treatment of the disease it will be neces- sary to irrigate the colon (see page 383). ENTEROCOLITIS, ILIOCOLITIS, OR DYSENTERY Of this disease there is a catarrhal, an ulcerative, a membranous, and a chronic form. The severity of the symptoms is greater in the ulcerative and membranous forms than in the catarrhal. The characteristic symptoms of this disease are colicky pains associated with mucus and blood in the stools. The character of the diarrhea depends upon the seat of the lesion. Inflammation high up in the bowel causes yellow and greenish stools ; in the lower bowel more mucus and blood are found and less of the undigested food ele- ments. The lower in the bowel the seat of the inflamma- tion is, the more severe the symptoms become; the tem- perature is higher, the prostration greater, and the stools are mixed with blood. When the lower colon and rectum are involved, in addition, there is tenesmus, which is a sensation of fulness of the rectum, with a constant desire to defecate. In the acute catarrhal form the mucous membrane DISEASES OE THE DIGESTIVE TRACT \2g of the colon is red, swollen, edematous, and in some cases ulcerated. Symptoms. — The onset is sudden. There are frequent stools, at first yellow, later green and mixed with curds, mucus, and blood, and sometimes material resembling chopped spinach. Temperature ranges from 102 ° F. to 103 ° F. The abdomen is distended and tender along the colon. Vomiting is rarely persistent. In the milder cases the mucus and blood continue to appear in the stools for from four to five days. The diarrhea continues for one or two weeks. In the ulcerative form the mucous membrane is swollen from edema and cellular infiltration. The latter causes superficial necrosis and formation of irregular ulcers which more or less undermine the surrounding mucosa. The symptoms of ulcerative enterocolitis are similar to the simple catarrhal form, but the disease is more pro- tracted and often marked by intermissions and exacerba- tions. The stools are more fluid and the mucus and blood persist. In membranous enterocolitis the mucous membrane is intensely swollen and covered by a false membrane. The separation of the membrane is followed by ulceration and sloughing. The symptoms are the general symptoms of dysentery plus those of the typhoid condition. The stools also contain false membrane and sloughs. The child grows pale, wastes, and assumes a senile appearance. Death may be preceded by coma and convulsions. The prognosis is always grave in membranous entero- colitis, yet recoveries do take place under favorable conditions. I 30 DISEASES OF CHILDREN FOR NURSES Treatment of Enterocolitis. — What was said under summer diarrhea holds good in ileocolitis. In older children there must be absolute rest, enforced use of the bed-pan, and liquid diet. For the pain apply externally hot fomentations and mustard poultices. Small pellets of ice introduced into the rectum every two or three minutes for half an hour will frequently relieve the tenesmus. In severe cases of tenesmus the physician will order thin starch-water injections containing 10 to 20 drops of laudanum to the pint. Irrigation is often practised. NURSING In diseases of the intestines the room should be light, cheerful, and well ventilated. Bathing need not be dispensed with unless the child is too sick to stand it. A woolen binder worn around the abdomen is often of use. Cold feet should be avoided and overdressing in summer is harmful. The feedings should be carefully prepared, the charac- ter of the stools reported, and the bov/el movements covered with carbolic acid, 1 to 20. It is better for the children to remain quiet, especially in the more severe forms of diarrhea. The temperature, pulse, and respirations should be taken at least twice a day. CHOLERA INFANTUM This is an acute disease of childhood characterized by high fever, vomiting, purging, and collapse. It is now generally taught that the severe symptoms of this disease are produced by the result of a toxemia or poisoning of the system. The poison is produced in the DISEASES OF THE DIGESTIVE TRACT 131 intestinal tract and absorbed. It receives its name from the similarity of the symptoms, in well-marked cases, to Asiatic cholera. In the majority of cases the disease attacks children who have been suffering from some form of intestinal trouble. At times children who have been perfectly well are stricken. Symptoms. — The onset may be gradual or abrupt. Diarrhea is usually the initial symptom. The stools are thin and serous or watery, and have a musty odor. Vomit- ing soon develops, and the irritability is so great that everything is rejected. The thirst is intense, and the temperature is very high, 1050 F. to 1080 F. ; the pulse is rapid and feeble and the urine scanty. Collapse follows, and is indicated by the pinched features, hollow eyes, sunken fontanels, and the cold surface of the body. Even at this time reaction may set in, but, more commonly, death results from exhaustion. Treatment. — Prophylaxis. — What has been said con- cerning prophylaxis, under previous diseases of the intesti- nal tract, should be practised to avoid such a form of the disease as this. General. — As everything swallowed during an attack only aggravates the vomiting, nothing should be given by the mouth except ice and iced champagne. The physician may find it necessary to wash out the stomach (Lavage, page 380) and irrigate the bowel (page 383). At times hypodermoclysis (see page 388) is resorted to. The serous or watery diarrhea so depletes the fluids of the body that this is necessary. The cold bath or tubbing is used to counteract the fever (page 365). 132 DISEASES OF CHILDREN FOR NURSES In collapse give a mustard tub, no° F., then place the child in a horizontal position, cover with warm blankets, and administer stimulants freely. Cholera morbus is a term given to a disease, similar to cholera infantum, in older children. The symptoms, however, are not so severe. This disease is seen in the summer season, caused by eating