BLANCH BOLTON, M. D., SAN PIEDRO, CALIFORNIA
Every physician who engages in general practice realizes the importance of diarrheal affections as a part of each summer's work, and he knows, also, that it means a good deal to himself, as well as to the mothers of these patients, that he is said to be "so good with children"—one of the indispensable qualifications of a family physician.
Diarrheal diseases in children under two years of age, were the cause, in New York, during five years, of more deaths than were caused by measles, scarlet fever, whooping-cough, typhoid and diphtheria for all ages. In other large cities a similar condition is found and the disease is not by any means confined to the cities.
Hot weather, teething, lowered vitality, overfeeding, improper food, all are factors which result in this heavy mortality, much of which is, of course, preventable, and right here the physician's work begins. Every year more attention is being given to prophylaxis and thus the number of cases and the mortality have been in recent years greatly reduced. Much, however, remains to be done in this line, both as to public sanitation and also as to the education of mothers in regard to the proper care and feeding of infants.
The idea that hot weather and teething are sufficient cause for serious cases of diarrhea is still prevalent among mothers and, perhaps, they have been confirmed in this by physicians, who overlooked the fact that hot weather and teething are both perfectly normal conditions, and should not interfere with normal functions. It is true that the greatest mortality does occur during the period of highest mean temperature, but the mortality is doubtless due to the fact that during the continuous hot weather of midsummer, ignorance and poverty allow a degree of unsanitary conditions, which would be impossible during colder weather.
Filthy "dish-rags," flies and indirect contamination of dishes, bottles, food, etc., by neglected napkins, lead to worse results in summer, because of the more rapid growth of micro-organisms, which find almost continuously an optimum temperature. Many foods enter the homes of the consumers during the summer season either in an advanced stage of decomposition or contaminated by products of advanced decomposition, ptomaines, etc. Unhygienic conditions are more common in hot weather, because of imperfect ventilation and contamination of the fresh air supply by products of decomposition.
Lowered vitality is indirectly another factor which in a general way must receive consideration. Loss of sleep and imperfect rest, due to impure air, overheated rooms, impatience and neglect on the part of tired and worn-out mothers, and due also to the short night and consequent long period of activity and noise, all, with perhaps the added strain of teething, tend to produce that worn-out condition which predisposes to almost any disease.
If, now, the child be overfed—and this is liable to occur now, just at a time when the child needs less food than in cold weather—the long hot days and unsatisfactory attempt at a midday nap, make the child cross and fretful. When he cries he is fed, and not being wiser than his parent, he eats. This unnecessary food distresses him and is the cause of more fretfulness and more feeding—too much and too often.
Improper food. As long as infants are placed at the table with adults and subjected to the same indiscretion of diet as the older members of the family, as well as being allowed to eat as much as it wishes of food entirely unsuited to children, serious disorders of the digestive organs will result. Decayed food, over-ripe fruit, decomposing milk, are very likely to be fed to infants or children at this time of year.
Improper clothing must not be overlooked as a cause. During warm weather small children are clothed, or rather unclothed, in such a way that the legs, arms, neck and sometimes feet, are bare, a sudden chilling of the air, such as often occurs at the close of the day, or in the afternoon, causes these exposed parts to chill and drives the blood to the visceral vessels, and, especially if the child has been overfed, the congestion may result seriously.
All the causes enumerated thus far can and should be explained to the parent. Boards of health and progressive physicians everywhere are giving publicity to these facts in relation to summer diarrhea. This is a duty which every physician owes not only to the patient and the parent, but to himself. How often we have given explicit instructions to a parent, only to find on our return that the instructions given either were not understood at all, or were deliberately disobeyed, because, through ignorance, they were thought unreasonable.
If the physician wishes to be successful in the treatment of summer diarrheas, he must have the intelligent co-operation of the mother or nurse. and the necessary education cannot all be imparted at the bedside during the rush of a busy season.
If you tell the mother under no consideration to give the child any food, solid or liquid, for so many hours—to give nothing but boiled water and the medicine—and find on your return that all the milk (undesirable in quality) that the thirsty child could drink has been given, do not lose your temper; do not blame the mother too much; if she had been properly and thoroughly enlightened, as mothers should be, she would not have done so. As to the giving of the medicine, she should follow instructions without knowing why, but the other is a case where she should know why. She needs educating. Meanwhile your patient needs a nurse.
As the child who is breast-fed will almost always escape these attacks, the mother should be advised to nurse her child if possible. Two factors enter into this injurious result from artificial feeding:
First—The artificial food will not serve the needs of the child so well as will that which nature provides, and, the child is not properly nourished.
Again—If the artificial feeding is an art, but imperfectly understood by the physician, what can we say of the mother's ability to properly manage it?
Pasteurized milk kept chilled and promptly used is preferable to raw milk, but pasteurized milk does not kill spores, and the acid forming germs being killed, the milk will remain "sweet" for some time, but if care is not used, the resistant spores will soon accomplish putrefactive changes which will make the milk, while still to all appearances sweet and wholesome, very dangerous.
Much can be done to reduce the mortality in the city by sending weak and poorly nourished children to the country, and by improving the condition of the milk supply.
Much has been done to improve the sanitary conditions of such districts in our large cities as are occupied by people too poor or ignorant to provide proper conditions. Country homes, however, are often in as great need of attention as are the tenement districts of our large cities, and it is to be hoped that in the near future we shall see state health measures taken which will result in better sanitation in country homes. The treatment of summer diarrhea, if begun early and conducted in accordance with modern methods, cannot fail in almost every case to produce the desired result.
If the case be far advanced, or the child lack vitality or proper surroundings or care, the prognosis is unfavorable, but a guarded prognosis should always be given, even in apparently favorable cases.
If the course of the disease can be arrested before serious lesions have been produced, much will have been accomplished. There are favorite prescriptions which have been productive of excellent results in the hands of leading physicians.
But the physicians who are really successful today in the management of these cases place no great value on these, good though they may be. If you wait for a suitable opportunity to use your favorite prescription, you will lose patients; if you do not wait, but go ahead and use that prescription in every case, you will kill several before you come to the right patient.
History proves it; statistics prove it; modern, up-to-date practice, as compared with the old way, proves it, and the old-timer who has not yet noticed it, should be told to stop and fall in line before any more innocent lives are needlessly sacrificed by the inordinate and untimely administration of astringents, opiates, antipyretics and stimulants in the effort to drive out the disease as if it were an entity which could be so treated, without considering the child. Not that drugs will not be needed, but that if we fully realize the nature of the task before us, we will use them differently, and with a precision and effectiveness which will enable us to spare the child the burden of combatting so great an amount of drug shock as formerly he must.
The first and most important step in the treatment of the case can be taken as the physician steps into the room.
The alimentary canal contains toxic matter, micro-organisms which are producing these toxins, and food which these organisms are feeding, and which they are converting into additional poison. Begin at once to rid the entire tract of this. No time need be lost. At once discontinue all food of whatever nature. As you may have considerable trouble to enforce this, do not fail to give it its full importance. For twelve to twenty-four hours the patient must be given absolutely nothing but boiled water (and medicine).
The great loss of fluids, and the fever, if present, will cause constant thirst, not hunger, and if you have no nurse, this point should be explained to the mother, or she will, in your absence, be unable to resist the temptation to feed the starving child to give it strength.
Lavage may be necessary to empty the stomach, or vomiting may have done this. A cathartic should be administered. Castor oil, followed by rhubarb, may be used.
Twice or three times the first day, and usually once each day following, the bowel should be cleansed with a warm (100°F.) enema. The first may be a soda solution, if the discharges are acid. The succeeding enemas may be, preferably, normal salt solution; allowing from I to 3 ounces to remain in the bowel, to be absorbed, and thus replace the fluids of the body which have been drained by the bowel discharges. Fever may be controlled by aconite. If the, eliminative process has not sufficiently advanced, however, and the manufacture of poisons is still in progress in the alimentary tract, you need not expect to get results from aconite. Aconite under such conditions is simply so much more poison added.
Ipecac in very mild doses will be useful in many cases, for its effect upon the gastrointestinal surfaces, but if given in dosage sufficient to depress, in some cases serious results will follow its use.
If the extremities are cold, heat must be applied, and if the skin be cold and pale, mustard may be used. Belladonna and hyoscyamus or their derivatives may be employed here, following indications. No effort should be made to control the diarrhea by opiates or astringents, nor even by the astringent after effect of rhubarb, as long as the bowel contains irritating matter, which should be removed.
Later, however, when the bowel is clean and excessive peristalsis can only do harm, opiates may be given in just sufficient quantity to produce the necessary quieting of the excessive peristalsis. Indications and contra-indications should be watched for carefully, before using opiates in all diseases of children. (And they should be used in very small doses, if at all.-ED.)
Bismuth may be given in small doses, its chief value being that of an indicator when blackened by the sulphur of decomposition (being eliminated as a sulphide), though it is also useful as a mild astringent and sedative to the sore surfaces with which it comes in contact.
In complicated or protracted cases, and in the severer cases, as cholera infantum, conditions must be met as found and frequently prompt action is required to save life.
In conclusion, let us remember, that the all-important point is to thoroughly and promptly empty the alimentary tract, cleanse it, and keep it as clean as possible; and that until this is done, it is not only useless, but highly injurious to administer food, antipyretics, astringents, or opiates.—Transactions National Association.
Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.