ENTEROCOLITIS

Fat1.00%orFat2.00%Milk sugar4.00%Milk sugar5.00%Protein0.75%Protein1.25%

They likewise advise whey and whey mixtures under these circumstances.

Fermentation.—Fermentation is often the cause of infantile indigestion. At times it is acute and may cause a decided elevation of temperature owing to the absorptionof the toxic substances formed as a result of the bacterial action. In almost every case of indigestion brought on by fermentation there will be an accompanying diarrhea. As a rule the carbohydrates are more liable to the attacks of bacteria in the stomach than the other food constituents.

Treatment.—The treatment consists first of starvation, no food being given for at least twenty-four hours. Then water or weak tea, sweetened with saccharin, may be given, but nothing else. The medical treatment must be left to the discretion of the physician. When the condition warrants a return to food the formula must be made weaker than that which has caused the disturbance. Malt soup mixtures, buttermilk mixtures, whey and albumen water may be added as the condition of the baby improves. In older children the period of starvation may have to exceed that of infants, but a gradual return to normal diet is made. Weak tea and toast may be given after the first twenty-four hours and well skimmed meat broths, soft-cooked eggs, liquid peptonoids, and malted milk added to the diet as the condition of the child improves.

The dietetic treatment for enterocolitis must be adjusted according to the principal symptom. In some of these cases diarrhea is most prominent, while in others constipation is the most marked symptom. Hence the diet must be such as not only to do no harm to the child, but one that will aid in his ultimate recovery.

The treatment for diarrhea, whether it is from fermentation or putrefaction of food, has already been explained. The grave danger in the putrefactive diarrhea is the absorption of the toxic substances which result from bacterial action upon the unabsorbed food material in the small andlarge intestine. In these cases auto-intoxication may develop and the baby may die before the condition yields to treatment. The entire intestine must be cleansed as a rule. The stomach of the baby may be reached with little trouble by using a small rubber catheter attached to a glass funnel and a solution of bicarbonate of soda. The bowels may be emptied by means of a soapsuds enema. Older children may be given oil, but this of course comes under the jurisdiction of the physician.

Constipation is one of the most frequent troubles visited upon people of all ages. “It is not a disease, it is a condition in which the number of stools is less or the consistency of the stools is greater than is normal for the individual at the given time.”[86]It may be caused by neglect of the bowels, which should be evacuated once or twice every day during infancy and once a day after that period. If the habit of emptying the bowels every day is established in infancy it adds much to the health and comfort of the individual during the entire remainder of life. Babies are sometimes constipated as the result of the opium administered in soothing sirups. Others inherit constipation, while still others are constipated by the taking of the wrong kind of food or too little food. In any case it is decidedly bad to resort to drugs, since the habit of taking cathartics is so easily acquired and so difficult to overcome.

Factors Inducing Constipation.—With artificially fed babies a formula which contains too high a percentage of diluent and too low a percentage of solids will cause constipation, chiefly because the solids are so completely absorbed that they have no residue to form feces. A formula with too low a fat content in proportion to its protein andcarbohydrates may cause constipation because the latter two constituents are almost entirely absorbed, and the feces, which is largely made up of the fat, is correspondingly small. Excess of fat, however, has been proved to be one of the chief causes of constipation in infants, as has also been the case with excess starch. Boiling the milk for the baby at times results in constipation. Hence sterilization is more frequently to blame for the condition than the pasteurization of milk.

Constipation during Second Year.—During the second year, if the child is given too much milk and too little solid food, constipation is very apt to be the result. A maximum quantity of from thirty-two to forty ounces may be given. In many diseases brought on by malnutrition, constipation is an obstinate condition to be overcome. This is especially the case in rickets and anemia.

Use of Laxative Foods.—After the baby is a few months old, orange juice is given between the morning feedings. Malted foods likewise exert a laxative effect. The higher the percentage of maltose, the more laxative the food. The nurse must keep this point in mind in feeding babies. With older children and adults, the question of diet for constipation is quite as important as it is for infants. Prunes or figs cooked with senna leaves and thoroughly strained furnish an excellent adjunct to the diet under such conditions. The coarse breads such as bran and Graham or wholewheat bread should be used instead of white flour breads. Care should be taken in advising a cereal diet for children, since cereals, with the exception of oats, are apt to be constipating. Fresh fruits, stewed fruits, and fresh vegetables are all good under the above-mentioned conditions. Young children require the vegetables strained or cut fine. Adults should include one coarse vegetable a day in their dietary to obviate the development of constipation. Children should be taught to drink plenty of water, andbabies should not be neglected in this respect. As a rule very few adults drink as much water as is necessary for the general welfare of their bodies.

There is probably no disease of infancy which has come in for more study in the past few years than scurvy.

Cause.—The disease is believed to be directly due to a deficiency in the diet of the antiscorbutic vitamine, known as “Water soluble C.”

Treatment.—For many years it was known that lime juice exerted a curative effect upon scurvy. But recently the efficiency of this fruit juice has proved to fall far short of that effected by either orange, or tomato juice.

Feeding experiments have proved that animals, fed upon rations consisting of dry food without the addition of green, will develop scurvy. And that the milk of such animals will show a deficiency in the “C” vitamine which will lead to a development of the disease in infants fed upon such milk.

Milk is, in fact, by no means a perfect food, so far as its vitamine content is concerned. First, because the presence of the vitamine in milk is so dependent upon the diet of the mother or the animal, second, because the pasteurization temperatures used to insure cow’s milk of purity from a bacterial standpoint, destroys in it the greater part of its antiscorbutic power. Either of which makes it necessary to supplement the formula of the artificially fed infant, and, in case of the former, the mother’s milk of the breast-fed baby, with orange, or canned tomato juice.

The amount of either of the fruit juices which is necessary to insure the child of a freedom from scurvy, is small, ranging from one-half to one ounce of strained juice daily, this amount is increased gradually until the child is taking from one and one-half to two ounces each day. It has beenfound advisable to administer the fruit juice between the two morning feedings. As a rule, the fruit juices are given at the beginning of the seventh month, but they may be given at a much earlier date, the time being adjusted by the physician.

Rickets, like scurvy, is being discussed by scientists both in America and abroad. The disease is widespread, particularly in its subacute form, and its effect upon the health of the child is so serious that no amount of effort to prevent its development should be considered too great.

Calcium Retention in Rickets.—The disease is characterized by a failure of the bones to lay down lime salts, this failure causes a softness and flexibility in the structure of the bones which permits them to bend into deformities. Then, too, it is a well established fact that any interference with the calcium metabolism in the body, will inevitably bring about disaster. (See Mineral Metabolism, page185.)

Factors Inducing Rickets.—According to Dr. Eddy, “It is impossible at present to determine whether rickets is a true avitaminose or a consequence of deficiency in a series of factors.”

Treatment.—For breast-fed babies it is necessary to adjust the diet of the mother to include more of the vitamine bearing foods, since milk contains vitamines only in proportion to the amount eaten in food. For artificially fed children, the giving of cod liver oil has recently been adopted as the surest and safest method of curing and preventing the development of the disease. Like treatment is used with breast-fed infants if the need arises.

The value of cod liver oil in this respect has only been recently recognized. Mellanby of England claims that the oil owes its curative and preventive properties to the presence of the “A” vitamine. But scientists in this countryhave not fully accepted this view. Eddy states, “It may be that the power of the oil is due to its ‘A’ vitamine content, in which it is known to be rich, or it may be due to a new vitamine, but the fact that the oil is a preventive in this respect gives the pediatrist another agent to insure normal growth.”

Sunshine as a Factor.—It has been found that the disease rickets is more prevalent in winter than in summer; this is believed to be due to the fact that sunshine during the summer months exerts a distinctly beneficial influence over the disease. Dr. Hess’s report of the good results which he has found to be derived from the use of the ultra violet rays as a substitute for sunshine in winter, would seem to confirm this view.

Malnutritionis not confined to the children of the poor, though it is more common with infants of parents who have not the means to secure the best milk and give them the benefit of wholesome surroundings and plenty of sunshine. But babies of people in moderate circumstances, and even of wealthy parentage, are at times badly nourished, and require the same exacting care, the same attention to the food, the fresh air, and the sunshine that the poorer babies need in order to survive. Malnutrition may be the result of insufficient food, and it may also be due to the lack of one definite food element. Again, it may be brought on by some deformity of the mouth or stomach, which make it impossible for the baby to get all the food which he requires for his maintenance and growth. He may be born prematurely and his digestive apparatus not be sufficiently developed to care for the amount or type of food necessary for his needs, or he may have some congenital weakness which interferes with the absorption and assimilation of his food. All of these points must be considered.

Evidences of Correct Feeding.—If the baby shows a steady gain, both in weight and growth of stature, without digestional disturbances, the food given him is probably correct, but it must be kept in mind that nutritional disturbances, such as rickets and scurvy, are slow in developing, and do not manifest themselves with anything like the rapidity of digestional disturbances. Hence the nurse must take care as far as she is able, not only to prevent the food from causing indigestion, but also to see that it is not given in such a form as to induce those graver and more lasting nutritional disturbances which affect the entire system from infancy throughout the life of the individual.

Breast Feeding versus Artificial Feeding.—There is no doubt about the fact that the breast-fed baby suffers less from digestional disturbances and has more resistance to disease than the baby fed even upon a perfectly prepared artificial food. The majority of diseases manifested by artificially fed infants have their origin in the following errors in diet.

Over-Feeding.—Resulting in acute gastro-intestinal disturbances (colic, enterocolitis, colitis, constipation).

Under-Feeding.—Resulting in chronic, and acute deficiency diseases (scurvy, rickets, malnutrition).

Evidences of Dietetic Errors.—The stools, showing characteristic evidences of excessive quantities of, protein, fat, or carbohydrates in the formula. Loss of weight or failure to gain. The development of deficiency diseases (scurvy, rickets, xerophthalmia, rickets and malnutrition).

Evidences of Correctness in Feeding.—Normal gain, freedom from gastro-intestinal disturbances, and deficiency diseases. Rosy cheeks, bright eyes, and a vigorous body.

Treatment in Abnormal Conditions.—The treatmentconsists in adjusting the diet to meet the needs of the particular disturbance manifested. Plenty of fresh air, sunshine and sleep.

Relapse.—One danger which the nurse must always be on the lookout for is the relapse into the acute stage. The diet is the chief treatment. In acute gastro-intestinal disturbances rest from food is essential for at least twenty-four hours. Some infants can easily endure starvation for this short period. However, when malnutrition has already been established, it is not wise to carry out the starvation treatment over-long. A cautious return to a normal diet may be made as soon as acute symptoms disappear.

Fevers in General.—It requires very little deviation from the normal to raise the temperature of a child. A slight attack of indigestion, a slight soreness of the throat, will bring up the temperature of some children out of all proportion to the seriousness of the disorder.

Diet in Fevers of Short Duration.—As a rule, in the fevers of short duration, such as intermittent fever, malarial fever, etc., the diet is a simple matter. Milk is given when it agrees, with buttermilk, koumiss, broths, and albuminized beverages to vary the diet.

Diet in Infectious Diseases.—When, however, the fever is induced by specific bacteria, such as in the case of typhoid and scarlet fever, the diet is a different matter altogether. The disease may be one in which the diet is the chief item of importance; such is the case with typhoid and scarlet fever, with the former because of its long duration, the increased rate of metabolism due to both the fever and the action of the bacteria making it necessary to increase the normal amount of food to meet the new requirements of the body; and with the latter on account of the kidney complications which must be guarded against, and which can only be handled by regulating the diet.

Infant Feeding.—The feeding of infants under febrile conditions resolves itself into an adjustment of the milkformula to meet the existing state of affairs. The digestion is always more or less disturbed by fever, especially during the early stages.

Restricting the Food.—It is not always possible to diagnose the disease immediately, so that the safe thing to do is to lengthen the intervals between the feedings for the breast-fed baby and to stop food entirely for twelve to twenty-four hours for those who are artificially fed, when there is any doubt as to the cause of the rise of temperature. Some mothers find it difficult, if not impossible, to institute this period of starvation. In these cases barley water or albumen water may be given at stated intervals. Many physicians give very weak tea, slightly sweetened, under the above conditions; it does no harm to the baby and relieves the mother from the belief that her child is being starved to death. In twenty-four hours, if the fever arises from disturbed digestion, some manifestation of the condition will be observed.

Bacterial Activity.—In cases of intestinal putrefaction the fever is apt to rise at an alarming rate and is controlled only by removing the cause. The proteins which have escaped digestion and absorption in the intestines furnish the best medium for the growth of putrefactive bacteria. Hence this food constituent must be given in its most digestible form.

Dietetic Treatment.—Milk in most instances is the best form in which to give protein food, especially to young children and babies. At times, however, it will be found that milk disagrees; it must be peptonized, or one of the fermented milks, such as buttermilk (Bulgarian culture), Eiweissmilch, or koumiss must be substituted. In cases where the putrefactive bacteria make it unwise to use milk at all, for a time the proteins should be furnished in the form of cereal gruels, and the juice of an orange strained and diluted given once or twice a day between the morning and evening feedings.

Wheyis contraindicated in cases where the fever is brought on by putrefaction in the intestine, chiefly because it furnishes one of the best mediums known for the growth of the offending bacteria.

Patience is required in handling the diet for fevers in infancy. As has already been stated, it requires a very slight cause to raise the temperature of a child, but for this very reason especial care must be observed that no enlightening symptom escapes the notice of the nurse.

Complications.—Tuberculosis or scurvy may be in an incipient stage, and may be overcome if recognized in time. The nurse has a better opportunity for observing changes in an infant or child under her care than the physician who comes once a day or less. The nurse should make note of these changes, that the physician may have a chance to regulate the diet accordingly.

Fluid Diet.—With children, as with adults, the energy output in fever is greater than in health, hence the need for plenty of fluids to help eliminate the waste products due to the increased metabolism. These fluids may consist of water, fruit beverages, cereal water, whey, and broth. It is well for the nurse to remember that when the child is confined to bed, he will not need so much food as he would if he were up and about, but that if the fever is of long duration, as in typhoid, the increased rate of metabolism must be met by an increased amount of food, as the ordinary requirement standards for a child in health cannot be applied to the diet of a child under these conditions.

Scarlet fever is an acute infectious disease, characterized by high fever, sore throat, a red rash, and a tendency to nephritis. The disease usually begins suddenly with an attack of vomiting; the temperature rises to 104° or 105° and on the first or second day a rash appears, first on the chest and neck, and spreads over the entire body. This lastsfrom three to seven days, desquamation begins soon after the rash disappears and lasts from two weeks to six, the palms of the hands and soles of the feet peeling last. The appearance of the tongue is very characteristic, being coated, and through this coating are seen a few bright red points, producing the well-known strawberry tongue. After a few days the coating disappears, leaving the tongue bright red. In mild cases the tonsils are enlarged and the throat very red. In severe cases there may be difficulty in distinguishing the disease from diphtheria without a culture being taken. The tendency of the child to develop nephritis during the second or third week makes the treatment largely dietetic in character.

Dietetic Treatment.—Milk is the chief diet for the first three weeks. If it disagrees, it should be modified or peptonized to suit the condition. Koumiss and buttermilk may be substituted when it is impossible to prepare the milk so that it will not cause digestional disturbances. This, however, is seldom found to be the case during infancy. Malted milk and even condensed milk, or some of the dextrinized and malted foods at times prove valuable when whole milk disagrees. But the nurse must remember that a baby runs a risk of developing nutritional diseases of a grave character if fresh milk is eliminated from the diet for any great length of time.

Older children may have plain vanilla ice cream and plain junket, oyster or clam broth made with milk, the oysters and clams carefully strained out. Lemonade and orange juice may be given, but no meat broths or albumenized beverages or egg dishes can be admitted to the dietary.

Development of Nephritis.—Nephritis must be guarded against. The skin, being covered with a rash, is put out of commission as an excretory organ; in consequence all of the work of this description is placed upon the kidneys. In the first part of this text the work of the kidneys was defined;it was found that they were the chief organs for the excretion of the end-products of protein metabolism. It can be readily understood that when these organs are given not only their own work but that of the other organs to perform, unless the food requiring the greatest amount of effort on the part of the kidneys is confined to those types which can be most easily taken care of, such as milk, the kidneys stand a great chance of becoming impaired. Such is the case in nephritis.

Convalescent Treatment.—The return to normal diet must be made with the greatest caution. Specimens of urine must be taken often, for in this way alone can the development of nephritis be reckoned with.[87]Should nephritis develop in spite of efforts to prevent it, a farinaceous diet[88]such as is given in these conditions must be resorted to.

After three weeks, if the patient shows no disposition toward nephritis, and if convalescence is progressing satisfactorily, the diet may be increased day by day, adding milk toast, cereals, cream soups, rice, baked potato, then custards and soft eggs, the soft part of oysters, broiled or baked fish, broiled breast of chicken, and, still later, rare beef and lamb chops. Meat, however, must not be given until all danger from nephritis has passed.

Diphtheria.—The feeding in diphtheria follows the régime given in acute fevers. The body must be kept in good condition. At the same time it is necessary to understand the complications which make the dietetic treatment of this disease assume a place of importance.

Complications.—It may be complicated by broncho-pneumonia, albuminuria, carditis, endocarditis, and dilatation of the heart. Anemia must be combated, but care shouldbe used not to push the diet to such an extent as to impose too great a tax upon the already weakened heart.

Dietetic Treatment.—While the fever lasts the diet must be fluid, milk, buttermilk, malted milk, and some of the proprietary infant foods such as Mellin’s Food, Eskay’s Food, and like preparations. Milk gruels, made with milk and some cereal such as farina, barley flour, fine cornmeal, arrowroot, strained oatmeal, etc., are at times more easily swallowed than the unthickened liquids. Liquid beef peptonoids, panopeptone, and like predigested beef preparations prove valuable in many cases.

Convalescent Diet.—As convalescence progresses, or in cases where the patient finds it easier to swallow a semi-solid than a liquid, soft custards, gelatin, well-cooked cereals, and ice cream may be given. Eggnog and milk punch are at times given, but only upon the advice of the physician in charge.

Rectal Feeding.—When the condition of the patient makes it necessary to nourish in other ways than by mouth, nutrient enemas[89]may be given. In certain cases of diphtheria, young infants can be fed more successfully through a tube inserted by way of the nose into the stomach than by feeding in the ordinary way. The formula is prepared in the same way as for bottle feeding, and is poured into a glass funnel and through the soft rubber catheter into the stomach. Care must be observed to prevent the patient struggling on account of the heart weakness which invariably complicates this disease.

In the early months of life it is probable that whooping cough is one of, if not the most fatal of the diseases to which the infant is subjected. The period of incubation of this disease is from one to two weeks, the cough at first not appearing different from those accompanying colds of allsorts. However, in from ten days to two weeks the characteristic whoop occurs, differentiating this disease from all others. The symptoms aside from the whoop are the difficulty of taking breath and the great prostration after the paroxysm and the frequent vomiting of the food, brought on by the violent coughing.

In very young infants the whoop does not always occur. But the child coughs and holds its breath until it is blue in the face. At times young babies may have convulsions. The so-called spasmodic stage, during which the child may have from a few to a great number of paroxysms of coughing a day, lasts from a month to six weeks, and in some cases even longer. As the disease declines the cough gradually disappears and the child appears to be suffering with ordinary bronchitis. The characteristic whoop may return at any time during the ensuing six months or year if the child has an attack of bronchitis and is inclined to cough.

Complications and After-effects.—The complications and after-effects of whooping cough give it a serious character. Hemorrhage may occur from the nose. According to Ruhräh: “Paralysis may follow from meningeal hemorrhage, broncho-pneumonia, acute emphysema, and collapse of the lung may occur. Diarrhea, convulsions, and albuminuria are also met with. Tuberculosis and chronic bronchitis may follow.”[90]

Dietetic Treatment.—The diet plays an important part in whooping cough. The serious complications and after-effects of this disease upon children necessitate a rigid observance of dietary laws. With infants it is always best, when it is possible, to give breast milk. As this is the natural food it requires less effort on the part of the digestive apparatus to become available. It has been proved that even during the time when the baby is nursing the milk is projected in spurts into the duodenum without waiting to be attacked by digestive enzymes in the stomach, andfor this reason the breast-fed infant is more apt to be efficiently nourished than the artificially fed baby, who loses his dinner by vomiting before absorption has had a chance to occur.

Diet under Ten Years of Age.—For children under ten years, a fluid diet is necessary, at least in the beginning of the disease while there is a fever, and later, if the vomiting is persistent. Milk, buttermilk, koumiss, broths, albuminized beverages, and cereal gruels such as barley and oatmeal gruel and arrowroot gruel can be given. Later, if the fluids are retained, cream of wheat, farina, junket, soft custards, and soft-cooked eggs may be added. Care must be taken in giving toast, unless it is softened with milk or broth, for the crumbs may bring on a paroxysm of coughing and vomiting. The best results in feeding with whooping cough are obtained by giving the food in small quantities and oftener. A few ounces given every two hours are less apt to be vomited than a larger quantity. It is also easier for the child to take the small amount after an attack of coughing and vomiting than it would be for him to attempt a larger meal.

Use of Stimulants.—In many cases where weakness is great, it has been found advisable to add some stimulant to the diet. With infants this is best given in albumen water, a small amount of good brandy acting better than other stimulants. With young children some of the predigested liquid beef preparations, such as liquid peptonoids, are found valuable. These foods are given alternately with the other fluid foods.

Hygiene and Sanitation.—Infants and children suffering with whooping cough require plenty of fresh air and sunshine. They must be kept out of doors as much as possible and sleep in well-ventilated rooms or sleeping porches. They must be protected from drafts and excitement, and never allowed to become over-tired. In this way the anemia which so often results from prolonged attacks of whooping cough is in a measure held in check. At times it is foundnecessary to give some kind of an iron tonic, but this comes under the jurisdiction of the physician instead of the nurse. When bad effects do occur in spite of all the care exercised during the attack of whooping cough, they must be accorded the treatment especially devised to meet the situation.

This is an acute, infectious disease characterized by a red eruption which appears on the fourth day. Measles is one of the most contagious of all the diseases of childhood. It may be acquired by direct contact with another case or by being in the room with a case. The infection may also be carried through the air and occasionally by a third person. Measles is more prevalent in the winter than in summer. In cities it often occurs in epidemics. The period of incubation is from ten days to three weeks, occurring generally at about two weeks after exposure.

The attack may begin with the child showing a languid attitude, complaining of headache. Then a cough develops, with nausea and fever at times. The fever is often high, reaching 104° F. on the second day. As a rule the fever gradually falls after the second day and becomes normal in almost a week. However, the temperature varies in different cases.

Complications.—Measles is not considered dangerous in itself, but the after-effects sometimes prove fatal. This is especially the case in broncho-pneumonia, which frequently develops during or after the attack.

The gastro-intestinal, as well as the respiratory, tract is attacked in measles, diarrhea being especially common. Very weak children have been known to develop gangrenous stomatitis; paralysis and tuberculosis[91]likewise develop in some cases as the direct result of measles.

Thus it is demonstrated that measles is not to be lightly treated. Even if it is not in itself fatal, the results of thedisease are so dangerous that the care of the nurse is especially necessary. The great trouble is that so often a nurse is not in attendance and the child suffers through ignorance of the mother.

Dietetic Treatment.—The dietetic treatment of measles is important. For infants milk is the exclusive diet, the formula for bottle-fed babies having to be weakened on account of the catarrhal condition of the gastro-intestinal tract. For older children it is necessary to confine the diet to fluids as long as the fever lasts, and at times longer if the stomach gives evidence of digestional disturbances. Milk is the chief food, with milk soups, buttermilk, and koumiss used to vary the diet. Orangeade and lemonade may be given to allay thirst. A return to normal diet must be made gradually, giving cereal gruels, milk toast, and broth before the more solid articles of diet suitable to the age of the child. When there are complications they must be treated, as in whooping cough, according to their symptoms.

Gastro-intestinal Disturbancesare responsible for much of the fever manifested during infancy and childhood.

Infectious Diseasesare all more or less accompanied by an elevation of temperature.

Incipient Diseases, especially tuberculosis and scurvy, may likewise cause a rise of temperature. The relief of either disease or the fever depends largely upon how quickly the conditions are discovered and the means instituted to overcome them.

Metabolism in Febrile Conditionsof children, as well as of adults, is rapidly increased, hence the energy output is greater, and for this reason the fluid intake must be augmented in order to eliminate the toxic substances produced as a result of the rapid breaking down of the body tissues.

The Kidneysare more or less strained to eliminate the products of the increased metabolism and for this reason itis especially necessary to adjust the diet in order to limit, as far as possible, the foods which add to the burden already imposed upon the organs of excretion.

The Skinis an organ of excretion which, under normal conditions, shares the work of the kidneys. In infectious conditions, accompanied by eruptions which more or less cover the entire surface of the body, this organ is temporarily out of commission, hence its work, as well as their own, must be accomplished by the kidneys.

Dietetic Treatmentin the majority of infectious diseases may be divided into three periods: Starvation, Fluid Diet, and Convalescent Diet.

Starvation, during which time no food is given for twenty-four hours or longer, in order to allow the digestive apparatus to rest and to give time for any substance which may be causing the elevation of the temperature to pass from the body. This treatment is also wise because it furnishes an opportunity for the symptoms of the disease to manifest themselves; Fluid Diet, given when acute symptoms subside, and Convalescent Diet when danger from relapse is over.

Scarlet Feveris treated with two main ideas in view—preventing the development of nephritis and relieving the condition should it develop.

Dietetic Treatmentis logically the only means of treating or relieving nephritis. For the first three weeks, during which time this complication is apt to develop, a milk diet is necessary. This may be in the form of whole milk, milk soups, malted milk, etc. At the end of this time, if there are still no symptoms of nephritis, a convalescent diet, beginning with cereals and soft toast and progressing through the simple digestible foods such as rice, baked potatoes, soft eggs, etc., may be given. This is continued until the patient is well on the road to recovery. Meat should not be added until practically all danger of nephritis is passed.

Nephritis.—If, during the course of the disease thiscomplication, should develop, the treatment described for acute nephritis on page 336 should be immediately instituted.

Diphtheria.—Dangerous complications at times develop as a result of diphtheria, making the treatment of this disease of the utmost importance. Heart symptoms, pneumonia, albuminuria, and anemia are among the complications to be dreaded and combated.

Dietetic Treatmentin diphtheria is most important. It consists of a fluid diet made up of milk, malted milk, or buttermilk. At times the condition of the throat makes a slightly thickened mixture more easily swallowed than one which is distinctly fluid in character, and for this purpose farina, arrowroot, or barley flour may be used.

Increasing the Diet.—As convalescence advances the semi-solids, soft toast, soft custards, gelatin, and cereals may be given. Should the heart show symptoms of being affected, the intake of fluid must be restricted.

Gavage and Rectal Feedingare at times necessary. Infants may be successfully fed by passing a small rubber tube through the nose into the stomach and administering the milk formula to which they are accustomed. Rectal feeding is likewise valuable in cases of extreme anemia accompanying diphtheria.

Care must be observed by the nurse in giving gavage to babies, since any struggling on the part of the child may result in death from heart disease.

Whooping Cough.—On account of the character of the disease and the proneness of the stomach to eject the food during paroxysms of coughing, dietary measures are more or less necessary in order to enable the child to receive sufficient food to cover his daily needs.

Complications.—Hemorrhage, pneumonia, albuminuria, diarrhea, and convulsions may occur during the disease, while tuberculosis and chronic bronchitis may follow as after-effects.

Dietetic Treatment.—Breast milk is by far the best foodfor the baby, in this as in all conditions. In whooping cough the fact that this fluid leaves the stomach almost as soon as it enters lessens the chances of the baby losing its meal by vomiting it.

Older childrendo well with frequent small meals, since they are not so apt to give rise to pressure which brings on the paroxysms of coughing and vomiting. When the meal is vomited, a second should be given in order to keep the child from suffering from malnutrition.

Stimulationis found to be necessary in certain cases. Albumen water containing a spoonful of brandy or some of the prepared beef preparations, such as liquid peptonoids, may prove valuable under the circumstances.

Measles.—Complications and after-effects developing as a result of measles make the dietetic treatment of this disease important. Gastro-intestinal disturbances, especially diarrhea, are apt to occur, and tuberculosis has been known to develop as a result of measles.

Dietetic Treatment.—The fluid diet as used in any acute febrile condition is used as long as the temperature is elevated. Milk, buttermilk, malted milk, and milk soups constitute the chief items in the diet. Orangeade and lemonade are found valuable in relieving the thirst.

(a) List the evidences of errors in the diet of infants; show how they may be corrected in the formula.(b) Outline the processes in the preparation of Eiweissmilch (protein or albumen milk). What constituent is particularly low in this milk, and how was its reduction accomplished?

(a) List the evidences of errors in the diet of infants; show how they may be corrected in the formula.

(b) Outline the processes in the preparation of Eiweissmilch (protein or albumen milk). What constituent is particularly low in this milk, and how was its reduction accomplished?

FOOTNOTES:[84]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.[85]Ibid.[86]“Diseases of Nutrition and Infant Feeding,” p. 307, by Morse and Talbot.[87]See chapter on Urinalysis, p.323.[88]Consisting of cereal gruels, rice, and other starchy foods.[89]See Nutrient Enemas, p.145.[90]“Diseases of Infants and Children,” p. 326, by Ruhräh.[91]“A Manual of Diseases of Children,” p. 319, by Ruhräh.

[84]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.

[85]Ibid.

[86]“Diseases of Nutrition and Infant Feeding,” p. 307, by Morse and Talbot.

[87]See chapter on Urinalysis, p.323.

[88]Consisting of cereal gruels, rice, and other starchy foods.

[89]See Nutrient Enemas, p.145.

[90]“Diseases of Infants and Children,” p. 326, by Ruhräh.

[91]“A Manual of Diseases of Children,” p. 319, by Ruhräh.

Predisposing Factors.—The majority of diseases affecting the stomach have as their predisposing factors, and owe their development to, one or all of the following conditions: (1) errors in diet; (2) disturbed secretory processes; (3) disturbed motility and tone.

It is probable that in the beginning the first factor was the chief offender in the case, bringing about the development of one or both of the other conditions. The other factors to be considered in this respect are heredity, occupation, poverty, and diseases which involve to a greater or lesser degree the digestion of the stomach and intestines. A child may inherit a weakened organism through excesses or disease on the part of the parent. If this weakness is not overcome while the child is growing, the probabilities are that the digestion steadily declines until in adult life it becomes a pathological condition. Lack of fresh air, poor and dirty food, unwholesome surroundings, crowded and badly ventilated sleeping rooms, insufficient water, and overwork, all act in making the digestion bad. These must be overcome if permanent good is to result.

Errors in Diet.—Errors in diet arise more often through ignorance than from any other cause. A child may be allowed to eat any and all kinds of unwholesome and unsuitable food. When the stomach rebels, showing the serious danger signals of nature, medicines are given but the diet is unheeded, until the time comes when even the medicinesfail to give temporary relief, and the organs of digestion are in some instances permanently impaired.

Disturbed Secretory Processes.—Consensus of opinion goes to show that the majority of cases of acute and chronic gastritis (catarrhal) and gastric ulceration are due primarily to a disturbance of the secretory processes, while the impaired motility and lack of tone in the stomach probably influence their development and aggravate the disease already present.

Composition of Gastric Juice.—In a former chapter the processes of gastric digestion were explained. The gastric juice, composed of from 0.2 to 0.3% free hydrochloric acid and several important enzymes and lipases, which act upon the proteins and emulsified fats, must be sufficient in quantity to assure good digestion, and when anything arises to interfere with the secretion of this fluid a deviation from the normal is bound to occur.

Disturbed Motility and Tone.—Again, it has been proved that good gastric digestion, like good intestinal digestion, depends more or less upon the way in which the food mass is mixed with the digestive juices and moved along the alimentary canal. Anything which interferes with the secretion of the juices or delays the food over its normal length of time in the stomach surely exerts unfavorable influences on the general metabolism of the food, for while, as we have already found, gastric digestion is not essential to the final utilization of the food in health, in disease it undoubtedly exerts a marked influence upon the general nutrition of the individual.

The lack of hydrochloric acid in the gastric juice lowers the resistance to bacterial action, for this constituent exerts a decided germicidal influence in gastric digestion, preventing fermentation with the production of organic acids andprobably alcohol. In conditions due to hypochlorhydria (lack of hydrochloric acid) foods which leave the stomach quickly must be given with enough of the other necessary constituents in their simplest and most easily digested form to balance the diet and prevent the occurrence of the other disorders as troublesome as the original disorder.

Dietetic Treatment.—The following points must be kept in mind in formulating a dietary for patients suffering from a deficiency of hydrochloric acid: (1) boil the drinking water to destroy any bacteria which may be present; (2) use carbohydrates in the form of starch rather than sugar, since starch is less liable to fermentation from bacteria than sugar; (3) limit the foods which delay the passage of the food mass from the stomach; fats pass into the duodenum more slowly than other foods and when fed with other foods delay their passage materially; (4) avoid the use of soda bicarbonate, as it tends to reduce the normal acid content of the stomach, thus preventing its germicidal action upon the fermentative bacilli; alkaline carbonates likewise inhibit the flow of gastric juices; (5) give especial attention to the attractiveness of the food served; let it be appetizing and savory, for by such means is the appetite juice and incidentally an increased flow of the gastric juices stimulated; (6) condiments and spices, meat broths high in extractives, and salt foods such as caviar and endives may be given at the discretion of the physician; it is seldom advisable to give the foods which are indigestible, even when they act as stimulants to the secretory cells of the stomach.

(Excess secretion of acid in the stomach)

The Effect of Excess Acid.—An excessive flow of hydrochloric acid has been found to be the cause of much of the acute and chronic gastritis, in fact more of the cases are traceable to an excess than to a lack of hydrochloricacid. This acid is more or less irritating in character, and the tender mucous membranes lining the gastric organ being constantly bathed in a secretion composed chiefly of acid must necessarily in time suffer a certain amount of irritation and inflammation, causing the development of a pathological condition which may be temporary or permanent, that is, it may result in acute or chronic gastritis, according to the amount of acid secreted and the length of time the hypersecretion is allowed to continue.

Determining the Acid Content of Stomach.—The difference between the cases brought about by an excess flow of hydrochloric acid are more or less difficult to distinguish from those caused by a lack of this constituent in the gastric juice, chiefly because in the latter case the organic acids formed as the result of bacterial action upon the food exert an equally irritating effect upon the membranes of the stomach, and the only sure method of determining the cause of the disturbance is by an analysis of the stomach contents, by which means the percentage of hydrochloric acid is determined.

Lavage.—It has been found advisable, in some cases of acute gastritis which do not yield readily to rest and liquid diet, to wash the stomach and allow a certain period of rest before giving any food; in this way the organ is rid of all of the offending material and thus has a better chance of a quick recovery.

Dietetic Treatment.—The following dietetic treatment for acute gastritis is advised: As the stomach is the chief seat of disturbance, all unnecessary work must be taken from this region for a certain period:

(1) That any obscure cause may manifest itself and the diagnosis may be rendered more accurately and more quickly.

(2) That by resting the organ the offending materials may pass out of the body and thus prevent further trouble.

Starvation Period.—Twenty-four hours of total abstinence from food may seem extreme, but as a rule in acute cases of gastritis it is the only sane and safe method of instituting a diet and thus beginning to overcome the cause of the disturbance. After the period of starvation the diet is begun with caution.

Fluid Diet.—Fluids should be given first in the form of well-skimmed broths, which may be reënforced with egg or cereal flours when the patient is very thin or anemic. Buttermilk, made with the Bulgarian cultures, koumiss and other fermented milk foods, liquid beef preparations such as peptonoids or panopepton, albumenized orange juice, cereal gruels treated with Taka diastase when it is found necessary, and peptonized milk. These may be given in from four to six ounces at a time, every two hours on the second day.

Increasing the Diet.—On the third day if the attack is slight the diet may be increased by adding toast, softened with peptonized milk, an ordinary serving (3 ounces) of farina, cream of wheat or rice, reënforced meat broth with two crackers, a cup of tea and a slice of toast, and one or two soft-cooked eggs. If the acute symptoms are still present on the third day, the diet advised for the second day must be continued until they disappear.

Convalescent Diet.—On the fifth day, if progress is satisfactory, lightly broiled chicken or a small piece of rare broiled beefsteak may be added to the diet and the meals reduced in number from six to four.

Relapse.—The patient must be warned against overeating or eating any of the articles which are known to cause an acute attack in his individual case, since one attack predisposes to another, and chronic gastritis may develop as the result of the continual gastric disturbance.

The treatment in chronic gastritis is very like that in the more acute form; that is, it must be combated by removing the cause. Lack of fresh air and exercise have much to do with the development of chronic gastritis, but even they combined with a judicious amount of rest would be wasted without a proper adjustment of the diet to cover the main points of the disturbance. As has already been mentioned, the cause may be a lack of gastric juice or it may be an excess of it; it may be intensified by anatoniccondition of the organ or from the food passing too quickly into the duodenum.

Test Meals.—As a rule it is not safe to make a snap diagnosis as to the cause of this disorder. Since in many instances the more serious disorders may be traced to a disregard for nature’s danger signals, the physician as a rule advises a test meal, this meal consisting of a glass and a half of water or a cup or two of tea without cream or sugar and from one to two slices of toast or water rolls. In from three-fourths to one hour or longer this is removed from the stomach by means of a stomach pump and analyzed, the result of the chemical and bacterial analyses forming the basis for diagnosis. This meal is generally given in the morning before any other food has been eaten.[92]

Dietetic Treatment.—The foods constituting the diet in chronic gastritis must be of the simplest character and prepared in the simplest manner. No fried foods are permissible. Pastries, griddle cakes, rich puddings and sauces, candies, and alcoholic beverages must be omitted from the diet as well as the following articles of food: pork, veal, shellfish except oysters, sardines, canned meats and canned fish, highly seasoned and spiced dishes, twice-cooked meats, vinegar,pickles, olives, cold slaw, pickled beets, catsup, mustard, coarse fibered vegetables such as cabbage, old onions, old turnips, and cucumbers, strong tea, coffee, or chocolate, rich cream or dishes made entirely of cream. In cases of excessive acidity due to a hypersecretion of HCl the extractives of meat are contraindicated, hence all gravies and outside parts of roasted meat must be omitted or limited in the diet.

Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. However, the character of this pain may be different, beginning soon after eating and radiating toward the back. This point may be affected by position. As a rule there is a tenderness over the seat of the ulcer. This is detected by palpation. Vomiting is one of the most general symptoms in gastric ulceration. This may begin from one to two hours after eating when the pain is at its height, or it may start as soon as food enters the stomach. As a rule the latter condition is found more often in very nervous women whose mental attitude affects the stomach to such an extent as to make it difficult to give them sufficient food to nourish them.

Hemorrhage.—Hemorrhage occurs in about half of the cases. The bleeding may be profuse and the blood bright red, or it may be less severe and the color of the blood changed by contact with the gastric juices to a dark brown like coffee grounds.

Excess Acid.—Hyperacidity is present in the majority of the cases, the percentage of HCl rising at times fifty percent. or more. Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening; and the constant development of cicatricial tissue brings about an obstruction of the pylorus, which if not relieved would allow the patient to starve.

Diet Treatment.—There are a number of treatments used in overcoming this condition. After the test meal and the diagnosis, the patient is placed upon a diet directed to overcome the chief symptom; for example, if the ulcer developed as a result of hyperacidity, the diet would be directed toward the relieving of that symptom. Boas[93]divides the treatment into three stages: (1) hemorrhage; (2) the intermediate stage; (3) the convalescent stage.

Starvation Treatment.—The majority of physicians institute a total abstinence period for the first stage, allowing no food or water to be taken by mouth. If the patient is very weak and anemic from the extended course of the disease, nutrient enemas are given from four to six times a day, alternating with saline enemas. This total abstinence continues from three to six days. Some cases have been known to be fed in this way for a month or six weeks with obvious success. However, this is not the rule but the exception. The diet must be adjusted to the needs of each individual, but a few general rules may be found helpful.

Dietetic Treatment.—Milk is the food generally utilized in the beginning. This may require peptonizing tobe digested, or it may have to be modified with limewater. Protein foods require HCl for their digestion. If these foods are fed they will absorb some of the excess acid, and in this way save the already irritated wall of the organ from additional irritation. When protein foods are given they must be in the form of soft-cooked eggs, scraped raw beef or beef juice, milk soups, and like protein foods.

When there is a dilatation of the organ there is more or less danger of fermentation taking place, with the formation of organic acids. These acids are exceedingly irritating, and every care must be observed to prevent their production. The following dietetic régime may be used as a guide in many cases of gastric ulceration:

Milk Diet.—½ glass (4 ounces) of milk peptonized at 115° F. for 20 minutes, every hour for three or four days. After this the interval between feedings is lengthened to two hours and the amount of milk increased to ¾ of a glass (6 ounces). This is continued from a week to ten days. The patient may be given a cup of well-strained meat broth, reënforced with an egg, once or twice a day, to vary the monotony of the diet. During the third week the milk may be given in the form of milk soups. These may be slightly thickened with barley, rice, or farina flour. The soups may be flavored with beef extract, but only a small quantity must be used, owing to the stimulating properties of these substances.

Water as a Stimulus to Gastric Secretion.—Water is exceedingly stimulating to the acid secreting cells of the stomach, hence it is advisable to limit the amount of water taken by mouth, allowing the patient just enough to wash out the mouth without swallowing any. The thirst is relieved by saline enemas.

It has been found, in many cases of gastric ulceration, especially those accompanied by hemorrhage, that glucose gives better results when used in rectal alimentation, thanany other substance. The strength of the solution varies from a five to a twenty-five per cent. solution. The number of glucose enemas given each day must be regulated by the physician. The method used is the same as in other rectal feedings, the enema is given “high,” and the flow regulated (drip-method).

Convalescent Diet.—During the fourth week, if the pain and discomfort are decreasing, soft-cooked or creamed eggs may be added to the diet, together with thoroughly boiled rice, farina, cream of wheat, wheatena and other finely ground wheat foods, wine or fruit jelly, sweetened slightly, or by using a small amount of saccharin for the purpose, junket and plain vanilla ice cream. At the end of the fourth week a very small portion of meat may be given once a day. It may be scraped raw beef spread upon toast or zwieback, or very lightly broiled beefsteak, broiled lamb chop or chicken (breast only), or boiled or broiled sweetbreads or brains. Spinach or green peas pressed through a sieve are the first vegetables allowed. After these young tender carrots and string beans may be given. Tea, coffee, and chocolate are eliminated from the diet. Milk flavored with coffee or cocoa may serve as a hot drink in the morning when the desire or need for such a drink is manifested. Butter is the best form of fat to be used in cases of gastric ulceration, but this must be given with the greatest caution. In cases where this fat is used in the form of cream, the amount must be cut down or entirely abandoned when there are evidences of butyric fermentation. Buttermilk, koumiss, and other fermented milk drinks are often found very satisfactory adjuncts to the diet. These may be given between meals, or at meals they may be substituted entirely for the milk when other foods are being given. They are not sufficiently nourishing to take the place of the milk diet otherwise. Albumenized orangejuice and cream, egg and vichy may be given to add variety to the diet.

Anemia.—When anemia is severe, as is often the case in gastric ulceration, the diet must be reënforced to overcome it. Some of the concentrated milk foods such as plasmon, encasin, sanatogen, etc., as well as the predigested meat foods, such as panopepton, liquid beef peptonoids, and like preparations, may be used to reënforce the diet.

Bland Diet.—In certain cases of gastric ulceration it has been found more advisable to use what is known as a bland diet. This consists of farinaceous foods such as farina, arrowroot, cream of wheat, corn meal, wheatena, malted breakfast foods cooked thoroughly and given in the form of gruels, and some of the proprietary infant foods, such as Mellin’s Food, Eskay’s Food, Racahout. These foods may require the addition of Taka diastase to make them more readily digested. They leave the stomach more rapidly than any of the others, and for this reason will be found to give less discomfort than the foods containing a high percentage of protein and fat. This diet, however, cannot be prolonged on account of its lack of balance. If the gruels are made with milk instead of with all water they become more evenly balanced. Samples of the stomach contents may be taken for analyses from time to time.

Lavage.—When lavage is necessary the patient must be allowed to rest after the process before being given food, otherwise it is apt to be vomited.

Instructions to Nurse.—The treatment for gastric ulceration is thus seen to be strenuous. In the beginning the patient is placed on a liquid or semi-solid diet, or is not fed at all for a time. This is done that the diseased organ may have a chance to adjust itself as far as possible and to give the physician an opportunity of studying the changes taking place in that organ. During the course of thedisease the general symptoms which develop from time to time, causing more or less pain and discomfort to the patient, are nervousness, which in some individuals amounts to melancholia, extreme anemia and an utter distaste for food, all of which require patience on the part of the physician, the nurse, and the patient herself to overcome. The nurse must see that the patient is not disturbed or made unhappy by having business or home cares talked over in her presence; she must be kept as cheerful and as comfortable as her condition permits and urged to use care in her diet. After the ulcer is healed, to prevent a return of the trouble she must be warned against eating too fast or when over-tired, and she must be advised against very hot and highly seasoned foods, for, in the observance of these simple common-sense precautions only is she even in a measure saved further attacks.

Special Diets Used for Gastric and Duodenal Ulcer.—There are several well-known diets used in these conditions. Among those that have been found most satisfactory may be mentioned the Sippi diet, the Lenhartz diet.

All of these diets require the most careful adjustment as to regulation of intervals of feeding, type of food material used, and method of preparation and administration of food.

The treatment is directed toward the reduction of the free hydrochloric acid in the stomach in order that the ulcer may have an opportunity for healing.

Sippi Diet.—Equal quantities of heavy cream and whole milk, beginning with ½ ounce each every hour during the day. Alkaline powders are given with the meal and one-half hour after the meal. These consist of 15 grains each of sodium bicarbonate and bismuth subcarbonate with the feeding, and 10 grains of light oxide of magnesia and 15 grains of sodium bicarbonate betweenfeeding. The cream and milk are increased at the rate of one-half ounce each at each feeding for two days, the powders are continued as on the first day. On the fourth day an egg is added to the diet, the milk and cream are given in quantities of one and one-half ounce each, every hour. On the fifth day two eggs are added. On the sixth day one helping of oatmeal or other soft cereal is added to the above diet. The diet is in this way increased until the patient is taking three eggs and nine ounces of cooked cereal each day in addition to the cream and milk mixture. The amount given at one time must be small, never exceeding six ounces (according to Carter, Howe and Mason).

An accurate control of the acidity of the stomach should be maintained, this is accomplished by withdrawing a certain amount of the gastric contents by means of the stomach tube.

The Lenhartz Diet.—This diet is likewise given in hourly feedings, consisting of milk and raw eggs in the beginning, then a small portion of sugar is added, next scraped beef is added to the milk, eggs and sugar, already given, then boiled rice. Next a small quantity of zwieback (or soft toast), and continuing in this way, chicken, and butter are admitted. In the beginning the quantity of milk is 100 c.c. and the number of eggs 2, given raw. It is served iced, and with a teaspoon. When the sugar is added it is beaten up with the eggs (20 gm.). The milk and eggs are divided into separate feedings and given at hourly intervals from 7A.M.to 7P.M.It is rarely possible to give the amounts called for in the Lenhartz diet after the sixth day, but as much as possible should be given without risking an acute disturbance. Women, as a rule, find it more difficult to take the full amount ordered than men.

The following outlines represent the diet for the first, third, sixth, seventh and tenth day:

FIRST DAY

THIRD DAY

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