Diarrheas of Children.
Synonyms.—Acute Gastro-intestinal Catarrh; Summer Complaint; Acute Gastro-enteritis; Cholera Infantum.
Definition.—In nearly all the infantile diarrheas, there is an involvement or irritation of the stomach as well, and frequently they occur in epidemic form. Especially is this true of cholera infantum. It may accompany an attack of indigestion, the patient being free of fever, or an attack may be attended by high temperature, great excitation of the nervous system, and extreme prostration.
The summer diarrheas are usually divided into three varieties:
(2) Acute dyspeptic diarrhea; (2) cholera infantum, or summer complaint; (3) ileo-colitis.
Etiology.—The greatest number of cases occur between the age of six and eighteen months, and are confined almost entirely to bottle-fed babies. According to Holt's Statistics, only three per cent, out of two thousand cases examined, occurred in children that were entirely breast-fed. While no class is exempt, the poor are the greatest sufferers. The second summer is commonly regarded as the most trying period in an infant's life, owing to the substitution of solids for fluids, and the eruption of teeth.
The most important causal factors in enteritis in children, are diet and temperature. Most artificial infant foods are rich in starch and sugar, and readily ferment in hot weather; this is especially true where the nursing-bottle and nipple are not kept absolutely sweet and clean. Neglect on the part of the poorer classes in this one important matter accounts largely for the great mortality among this class of patients. The disease may begin as early as May, progressively increasing until July, when it reaches the maximum; then gradually declines till August or September.
Booker has isolated forty varieties of bacteria, found in the stools, and probably each or all possess some pathogenic properties, and, when found in milk, may produce important changes. detrimental to digestion.
Pathology.—The mucous membrane of the large and small intestine generally shows catarrhal inflammation, and when the disease assumes a chronic form, follicular ulceration is not uncommon. A fibrinous exudate (Croupous Enteritis), a rare condition, affects the lower part of the ileum and colon. As a result of the diffuse watery diarrhea, the liquid parts of the blood are decreased, anemia being quite marked. Not infrequently the spleen is enlarged.
Clinical Forms.—Acute Dyspeptic Diarrhea.—The disease may come on gradually, the general health not being much affected for a few days, though the stools are quite frequent, and consist of curds, undigested food, feces, and gas, offensive in character and of a greenish or yellowish-green color. The child soon becomes peevish and restless at night. At other times the attack comes on suddenly, with vomiting, colicky, griping pains, and a fever which rapidly attains a temperature of 104° or 105°. Not infrequently, in nervous children, the disease is ushered in with a convulsion.
The abdomen becomes distended, is sensitive, and the child flexes the limbs on the abdomen for relief. If bottle-fed, the stools contain greenish curds, gas, and feces. If older, unripe fruit is apt to form an important part of the stools. If not arrested, it may terminate in cholera infantum or ileo-colitis.
In dyspeptic diarrhea, the pain is griping in character, and the abdomen is distended, while in cholera infantum the stools are "eatery in character, and the abdomen is apt to be flat or collapsed; and in ileo-colitis the pain is tenesmic, and the stools contain mucus or mucus and blood.
Cholera Infantum.—The disease may be preceded for twenty-four or forty-eight hours by diarrhea, the stools being loose and fecal in character, and very offensive. Soon, however, the child becomes thirsty, greedily taking anything of a fluid character, and cries and frets constantly for water, crying for it when brought in its presence. Fluids, however, are rejected as soon as swallowed. The stools now become frequent, are large and watery; losing their fecal character and odor, the napkin often being stained a green or brown color, but devoid of feces.
The prostration is rapid and extreme, and the plump, rosy child can scarcely be recognized in twenty-four or forty-eight hours after an attack. At first the skin is dry and harsh, the pulse small and rapid, and the child is restless, and can not be kept quiet in bed, but must be changed almost constantly. The temperature runs very high, ranging from 103° to 108°.
Cerebral complications are first noticed by the child rolling the head from side to side. The head now becomes hot, the face flushed, the child cries and frets constantly, or, if it drops asleep, the eyes are only partly closed, and the child is soon awakened by a sharp cry.
As a result of the frequent watery stools, the abdomen becomes flat, the eye is sunken, the nose pinched, and the tissues inelastic, and the stage, of collapse is ushered in. The extremities now become cold; the nose, lips, and ears become blue, vomiting ceases, the stools lessen in frequency, the pulse is small and thready, the child passing into a comatose state, and death soon terminates the case; or reaction takes place, the pulse becomes stronger, the body regains its warmth, and the child enters the convalescent stage.
The disease may run a very rapid and fatal course, death occurring within twenty-four or forty-eight hours; or it may be prolonged three or four days, each additional day of life adding to the patient's chance of recovery.
Ileo-colitis.—This is the dysentery of childhood, the symptoms depending upon the extent and location of the inflammation; thus, when the ileum is the chief seat of the inflammation, the stools will contain fecal matter, while mucus and blood compose the stool, if the colon receive the force of the attack. Generally, however, both are involved, and the stools at first are composed of feces, undigested food, and mucus. An attack may follow acute dyspeptic diarrhea, or it may develop suddenly.
Fever early develops, the temperature ranging from 102° to 104°, the pulse small and frequent, the skin hot and dry, urine scanty and high-colored, and nausea and vomiting frequently attend. The stools are greenish, and for forty-eight or seventy-two hours contain fecal matter; but as the disease progresses, they are composed of mucus and blood, and in some cases blood alone.
The stools are attended with griping, colicky pains, the tenesmus often resulting in prolapsus of the bowel. The abdomen is distended, and there is pain and tenderness along the course of' the colon. The stools vary in number, from two or three to thirty per day. If not early relieved, the child rapidly loses flesh and strength, the face becomes pinched and haggard, and the child may die from exhaustion.
Treatment.—The treatment of the various forms of summer complaints may be divided into hygienic, dietetic, and medicinal.
Hygienic.—The laity as well as the profession, are beginning to realize as never before the necessity of fresh air, not only in the treatment, but also in the prevention of the disease, and cities vie with each other in providing park facilities, playgrounds, and fresh-air funds for the overcrowded portions of our great cities. Fresh air is absolutely necessary to the life of these little patients, and, when it is at all possible, they should be kept much in the open air. Among the more favored classes a trip to the seashore or mountains works wonders in a very short time.
Bathing is beneficial, not only in insuring cleanliness, but also in carrying off excessive heat. The soda bath will prove of great benefit, the child being sponged off every few hours when the temperature range is high. Especially beneficial is sponging the head with hot water when there is determination of "blood to the brain, as manifested by rolling of the head.
The clothing should be as light and loose as possible, and during the heat of the day should consist of only a slip and napkin, changing to flannel during the night, if the night-air becomes cool.
Dietetic.—Since errors in diet are responsible for a very large per cent of summer diarrheas, the dietetic treatment will at once be recognized as one of vast importance; and we are not to forget that digestion is arrested in nearly all these cases, and that nourishment is to be given only in the blandest form and in very small quantities at a time.
Since over ninety per cent of summer diarrheas occur among bottle-fed children, our first attention will be turned to the bottle and the nipple. Every artificially fed baby should be furnished with at least two nursing-bottles, and several maroon or black nipples, and a crock of soda-water, in which to place the bottle after each feeding.
Never allow a nursing-tube to be used in a bottle, as it is almost impossible, to keep it sweet and clean in hot weather. After each feeding, the bottle should be thoroughly rinsed with hot water, and placed in soda or lime water until the next feeding, the nipple thoroughly turned and rinsed, and placed in cool, sterilized water. The food should be prepared fresh for each feeding, or else kept in a sterilized bottle in a refrigerator, and heated at each feeding.
In the selection of the food much depends upon the condition of the stomach. Some will not tolerate milk in any form, and small quantities of albumin or rice-water or toast-water will be the only nourishment retained. Others will do nicely on cow's milk diluted with barley-water; this is a favorite with me, and, when it can be taken, receives first choice,—three parts milk and one part barley-water. Sherry or pepsin whey is another favorite food.
However, there is no food that will agree with all patients; in fact, we might say that each patient needs a special study as to foods, and Horlick's malted milk, Mellin's food, Carnrick's lacta preparata, Fairchild's peptogenetic milk, and Eskay's foods are the most likely to meet with favor; but whatever food is selected, it must be given fresh each time and in small quantities.
Water.—Pure water may be given freely to cleanse the stomach; especially in cholera infantum, will we find great irritation of the stomach, and even a teaspoonful of water will be rejected. In such cases it is well to allow the patient to drink several ounces, and in this way wash out the stomach. The bowels may also be irrigated or flushed with plain water.
To allay the intolerable thirst, small bits of ice placed in a cloth may be given the child to suck, which gives great relief; or teaspoonful doses of white liquid physic may be given, well diluted in water, say one teaspoonful of white liquid physic to a half glass of water.
Medicinal.—In acute dyspeptic diarrhea, where there is offending material in the bowel, there is nothing better than the old neutralizing cordial, though some prefer castor-oil. This is to be followed by the small doses of neutralizing cordial, or, if there be much fever, aconite three to five drops, and ipecac five to eight drops to half glass of water, a teaspoonful given every hour.
If the tongue be broad and pale, nux vomica drops two, to water four ounces, and a teaspoonful every hour, will replace the above. Where there is colicky, griping pains, colocynth three to five drops, will be added to four ounces of water, and a teaspoonful given every hour. Where the stools are greenish in color, lactic acid 3i, to water four ounces, will give good results. Chamomilla will also be well received in similar conditions. If the tongue be pasty, sodium sulphite 10 - 20 grains, to water four ounces, will be found of great value.
Where the stools are watery and green, arsenate of copper will give good results; about as much of the second trituration as will lay on a dime, will be placed in a half glass of water, and a teaspoonful given every hour.
If atony of the bowel exists, bismuth subnitrate or subgallate may be given. Colonic flushing may be used in some cases.
Cholera Infantum.—The stomach may be washed out by allowing the little patient to drink freely of water with a little bicarbonate of soda and the bowels flushed by a normal saline enema.
To allay the nausea and retching, aconite two drops, ipecac five drops to water four ounces, a teaspoonful every hour, will often accomplish the desired object. If not, place about twenty grains of the neutralizing powder in a cup, and add four ounces of hot water and a teaspoonful of brandy, and give in small sips. This is especially useful, if the fever is not high.
Rhus tox. five drops to water four ounces, and given every thirty or sixty minutes, will quiet the irritable stomach, where there is great cerebral spinal irritation.
Nux Vomica.—If the face is pale, tongue broad, lips full, two drops of nux, to water four ounces, will answer better.
Gelsemium.—When the child is restless and constantly rolls his head, add fifteen drops of gelsemium to a half glass of water, and give a teaspoonful every thirty or sixty minutes. With the above symptoms the head is hot, and the best results can be obtained, not only in cooling the head, but in quieting the restless condition, by sponging the head with hot water. Do not lay a cloth on the head, as the heat will be retained, but have one attendant gently sponge the forehead, while another attendant gently fans the patient; in this way the head can be rapidly cooled and the patient obtain rest.
Where the patient starts and cries out in his sleep, rhus tox. will be found beneficial. For the bowels, the first trituration of the monobromide of camphor, in three or five grain doses, or the small dose of the second trituration of arsenite of copper, will not disappoint.
Saline Solution.—Where the system is drained of its fluids, as noted in the flabby muscles, the pinched face, the cold extremities, the subcutaneous injection of four or eight ounces of normal saline solution (sodium chloride 1 drachm, aqua 16 ounces), will give better results than any internal medication. From eight to sixteen ounces can be used in twenty-four hours.
Ileo-colitis.—Here we have an inflammation of the ileum and the colon, and the treatment will be similar to that for all irritable and inflamed mucous membranes. Aconite and ipecac for the small, frequent pulse, elongated tongue, reddened at the end and edges.
Colocynth for colicky pain and the tenesmus and bearing-down sensation. Dioscorea, where there is tenderness over the abdomen. Where the fever is slight, the tissues full, and an astringent is permissible, bismuth subnitrate will give good results.
When the tenesmus is very severe and almost constant, an enema of opium and starch-water, ten to twenty drops of the former, to a tablespoon of the latter, will quiet the straining, and give prompt relief.