CHAPTER XII

DISEASES OF THE INTESTINAL TRACT

ACUTE AND CHRONIC DIARRHEA (CATARRH), ENTEROCOLITIS, DYSENTERY, CONSTIPATION, APPENDICITIS, CHRONIC CONSTIPATION, AUTO-INTOXICATION

Diarrhea, like gastritis, may be a symptom of many diseases and a result of many digestional disturbances. Enteritis, enterocolitis, dysentery, typhoid fever, and certain cases of tuberculosis and syphilis are all accompanied by an inflamed condition of the mucous lining of the intestinal walls, and in each of these pathological conditions we may find diarrhea as a resulting symptom.

~Causes.~--Diarrhea may be acute or chronic in character. It may be brought on by errors in diet, warm weather, certain drugs, ptomaines, bad hygiene, polluted water or milk, and by overeating. Idiosyncrasies against certain kinds of food have been found in both adults and children; these idiosyncrasies are manifested by pain and diarrhea whenever the offending foods have been eaten. Acute diarrhea has also been brought on in children by the drinking of cold lemonade when over-heated.

~Diarrhea in Children.~--All diarrheas in children, and especially those developing during the hot months, must be looked on with suspicion and given immediate attention before they have an opportunity to develop serious features which may terminate in death before the seriousness of the condition is realized.

As a rule, almost any diarrhea in children will raise the temperature. This does not occur so often with adults unless the diarrhea results from infectious fevers, ptomaines, etc., in which case it may rise suddenly and to a considerable height.

ACUTE ENTERITIS (DIARRHEA)

~The Bowels.~--The symptoms of this condition are too liquid or too frequent stools, the number varying from three to twelve or more a day. They may be greenish yellow in color and contain particles of undigested food and mucus. In prolonged diarrheal attacks the stools sometimes contain blood.

The attack may be accompanied by more or less pain of a colicky nature, due to the formation of gas in the intestinal tract. In ptomaine poisoning this pain is sometimes very intense. As a rule the intestinal tract is emptied by means of salt, oil, etc., but this is generally directed by the physician. A soapsuds or salts and glycerin enema to flush the colon will often give quick relief by dispelling the gas.

~Starvation.~--The entire digestive tract requires absolute rest for a certain period; no food and very little water, the latter in the form of bits of ice only, are given for a period lasting from twelve to thirty-six hours or more, depending upon the violence of the attack and the condition of the patient. This is to allow the toxic substances which are probably causing the disturbance to pass out of the body, either in the feces or in the urine. When the acute symptoms subside, that is, when the pain and distention of the intestines have disappeared, and the bowel movements become more normal in number and character, the dietetic treatment suitable to the condition is instituted.

~Dietetic Treatment.~--The first day the patient is given a small cup of weak tea, half a glass of buttermilk or peptonized milk, or a cup of well-skimmed meat broth, every three or four hours. If the patient is weak, the nourishment may be given oftener, and in those cases it is often found advisable to give a small amount of alcohol in the form of brandy in albumen water, or panopepton or liquid peptonoids. These may be administered in tablespoonful doses every two hours. Whole milk, unless it is peptonized, and at times even then, is not advisable in diarrheal conditions on account of its liability to form curds which decompose with the production of toxic substances, known to be exceedingly irritating to the already inflamed mucous membranes lining the intestinal walls.

~Increasing the Diet.~--As the diarrhea and inflammation subside, the following foods are gradually introduced into the dietary, keeping in mind always that a return of the acute symptoms is apt to occur. Hence the patient must never be overfed. It is better to err on the side of too little than too much food during the early convalescent period.

~Diet.~--Soft-cooked eggs, toast (slightly buttered), cocoa made with water instead of milk, chicken, calf's-foot or wine jelly; later, well-cooked rice, junket, and soft custard; still later, lightly broiled beefsteak, lamb chops, chicken, squab or quail, sweetbreads or brains. Not until the patient is entirely free from all symptoms of diarrhea or intestinal disturbance may the following foods be given: cream or cream dishes such as cream toast, cream chicken, or cream soup, raw or stewed fruit, green vegetables, salt foods, spiced foods of any description; pastries, confectionery and desserts in general, unless they are simple in character and are sweetened with saccharin instead of sugar, as the latter substance is particularly susceptible to fermentation.

~Anemia as a Result.~--Anemia is one of the most common results of prolonged diarrheal attacks, especially in those toxic diarrheas resulting from infectious diseases, dysentery, etc. The blood-making tissues suffer from a lack of nourishment and are in consequence incapable of producing blood of the best quality. Hence the starvation treatment cannot be carried on over a very extended period or the resulting anemia may be more difficult to overcome than the original trouble.

~Selecting and Regulating the Diet.~--The following points must be kept in view when regulating the diets of individuals who are prone to develop diarrhea:

~Preparing the Diet.~--Only such foods as are known to agree with the individual, and these prepared in the simplest manner possible, must have a place in the dietary.

~Fermentation.~--All foods that are subject to fermentation either in the stomach or intestines must be withheld, at least until the attack is well over. Sugar is an example of such foods; saccharin may be substituted when necessary.

~Avoidable Foods.~--Pork, veal, and shellfish must be left out of the dietary, possibly for months, since they have been found frequently not only to bring about a return attack of diarrhea but also to have been the cause of the original one.

Fatty foods of all sorts had best be avoided as long as there are symptoms of diarrhea; these foods are handled with difficulty by the digestive apparatus and impose extra work upon the intestine, which is already taxed by the disease.

~Restricting Fluids.~--Fluid foods should be more or less limited in the diet, since they require more effort on the part of the intestines than the more concentrated foods.

~Proprietary Foods.~--Certain proprietary infant foods[94] are at times found to be exceedingly valuable, since they furnish food in a concentrated and digestible form. Among these Mellin's Food, Racahout, and Imperial Granum may be mentioned.

CHRONIC ENTERITIS

~The Stools.~--When the diarrhea is chronic in character, the character of the stools indicates the seat of the inflammation. When there is a great deal of undigested food found in them the upper part of the bowel is more affected; when the stools contain more mucus than food the lower bowel is the chief seat of the trouble. The frequency and fluidity of the stools impose a great strain upon the entire body, causing a progressive emaciation and anemia.

The treatment is similar to that instituted in acute attacks. The starvation regime cannot be carried out for a long period. Efforts must be made to ascertain the cause of the trouble and to overcome it. This is, as a rule, more easily accomplished with adults than with infants and children.

~Dietetic Treatment.~--The diet is the chief point of observation and attention. The same care must be observed as is found necessary in the after-treatment of acute diarrhea. The patient must be cautioned not to eat indigestible foods or those which are known to cause trouble in this respect. She must be warned against eating when over-tired.

ENTEROCOLITIS

Enterocolitis is an inflammation of the lower intestines and colon. The stools contain more mucus than those occurring when the inflammation is higher up in the intestines and blood is also more frequent in these stools. The prostration is more marked and the fever apt to be higher than in ordinary diarrheal attacks. However, acute attacks of enterocolitis do not produce the marked anemia or the emaciation which are so common in the chronic cases of enteritis.

Dietetic treatment the same as that used in acute diarrhea.

ACUTE DYSENTERY

Dysentery is a disease in which the seat of inflammation is the colon. The bowels are distended and tender, the pain at times is acute and spasmodic, and the fever moderate. The constant desire to defecate and the straining which accompanies each effort, as well as the small stools, containing both blood and mucus, furnish the characteristic symptoms of this disease. Rest in bed is absolutely necessary; the patient must be induced to use a bedpan.

~Dietetic Treatment.~--The diet consists entirely of liquids as in acute diarrhea, the same careful regime being observed as in those conditions. The soreness in the abdomen is at times relieved by spice poultices or a hot turpentine stupe.

CHRONIC DYSENTERY

When the above conditions become chronic, the patient loses weight and strength rapidly, becomes anemic and emaciated. The treatment, like that used in the acute disease, consists of rest and liquid diet. The medicinal treatment is left entirely in the hands of the physician.

APPENDICITIS

Appendicitis is an inflammation of the vermiform appendix. It may be acute or chronic in form.

~Symptoms.~--The disease is manifested by sudden pain in the right side, tenderness over the seat of the inflammation, and a localized rigidity of the right iliac fossa. The attack is as a rule accompanied by fever which may run as high as 103 deg. or 104 deg. F. The patient may suffer from nausea and vomiting. Constipation is generally an annoying symptom of the disease.

~Rest in Bed.~--The treatment of the acute attack consists of total abstinence from food for twelve or more hours until the most acute stage has passed and the patient either passes into the hands of the surgeon or the symptoms begin to subside in violence. It is necessary that the patient be kept in bed, not being allowed to rise for anything. The nurse must make him understand that his recovery, possibly his very life, depends upon his absolute quiet during the early stages of the disease.

~Dietetic Treatment.~--When the first acute symptoms have passed, the diet must consist of fluids, well-skimmed meat broths, buttermilk, peptonized milk, albumen water or albumenized orange juice. No solid food must be given until the acute symptoms have disappeared. When the tenderness in the right side has entirely left him and he no longer suffers the pain or nausea, a gradual return to a normal diet may be made. The patient must be cautioned against eating indigestible foods, as an attack of intestinal indigestion may readily start up an irritation in the susceptible appendix and cause a second attack of appendicitis which is often of a more serious nature than the first.

~Convalescent Diet.~--The return to solid food is made gradually as in other intestinal disorders, by giving the most digestible foods first. Soft toast, soft eggs, fine cereal gruels, well-cooked rice, well-baked white potatoes, meat, wine or fruit jellies; then lightly broiled beefsteak, lamb chop, chicken, sweetbreads, or brains given in small quantities until the intestinal tract has regained its vigor.

~Foods to Be Avoided.~--Highly seasoned foods must be avoided on account of their astringent qualities, which may cause constipation. Long, tough-fibered meats, coarse vegetables, rich foods, in fact anything which may cause intestinal indigestion, must be eliminated from the dietary. A decomposition of the foods lying in the lower part of the small intestine is dangerous to such individuals, since such products are highly toxic in character and exceedingly irritating to the already tender appendix.

CHRONIC CONSTIPATION

Chronic constipation is so universal a condition that it must be treated and overcome whenever it is possible. This condition is not only the cause but the result of disease. It may be induced by improper food, poor hygiene, sedentary habits, lack of exercise, the taking of drug preparations such as cough sirups which contain opium in some form, the constant taking of cathartics and enemas, or it may be an hereditary condition.

~Diet, Exercise, and Fresh Air.~--The chief means of overcoming this deplorable chronic condition is by regulating the diet and increasing the amount of exercise in the fresh air.

At times it is necessary to resort to artificial stimulation of the intestinal movements; at others, on account of the disease of which it is only one of the symptoms, it is dangerous to irritate the already inflamed mucous membranes lining the intestinal wall. In these cases the physician prescribes the method of procedure. In ordinary cases, however, the following suggestions may be used as a guide in overcoming the condition.

~Available Foods.~--It must be borne in mind that the food must not be too concentrated in character or it will be so completely absorbed as to leave little or no residue for the feces, and since the waste products of metabolism, both of food and body materials, must be eliminated, a certain amount of fecal matter is necessary to assist in this work. Vegetables, such as celery, turnips, lettuce, asparagus, string beans, spinach, and beans, lentils, lima beans, and onions; fruits, such as raisins, figs, and prunes; and cereals which have not had all the bran removed, such as cut oats, cracked wheat, etc., on account of the cellulose they contain, act admirably in overcoming chronic constipation. It is found, however, that when even these are not sufficient in certain cases, bran added to the food, either alone, with the breakfast cereal, or in the form of biscuits, muffins, or cookies, will give just the necessary amount of ballast to the food mass to make it stimulate the peristaltic movements by its pressure upon the intestinal walls.

~Stimuli to Peristalsis.~--Foods yielding certain acids exert a stimulating action upon intestinal peristalsis.

~Available Foods.~--Those particularly valuable for this purpose are limes, oranges, apples, prunes, figs, raisins, and most fruit juices (with the exception of blackberries, which are constipating), tomatoes, and rhubarb. The fruit juices may be diluted with water or carbonated water (in the latter case the action is increased because of the gas contained in the water), and taken the first thing in the morning, or the fruit may be eaten at night before retiring, and in the morning on an empty stomach. Prune pulp or prune jelly may be given to children as well as to adults. The action of this fruit is augmented by the addition of senna leaves. A conserve made of prunes, figs, and raisins given in teaspoonful doses at night and before breakfast often gives splendid results in curing chronic constipation.

~Gas-forming Foods.~--The eating of foods which give rise to a slight formation of gas owing to their tendency to ferment likewise acts as a stimulus to intestinal movements. Among these may be mentioned honey, molasses, cauliflower, cabbage, spinach, and onions. If the honey and molasses are poured on bran muffins or biscuits, on breakfast food, or added as sweetening agents to cookies, they will be found particularly valuable. Care must be taken, however, not to give too much of either of these foods or they will disturb the digestion and do more harm than good.

~Use of Salt Foods.~--Foods such as herring, caviar, anchovies, ham, etc., on account of the salt they contain, exert a stimulating effect upon the movements in the small and large intestines. Graham bread, spread with brown sugar, molasses, or honey, makes an acceptable addition to the meal of the majority of children and to that of many adults.

~Fats and Mineral Oils.~--The use of fats is often recommended; olive oil may be given in tablespoonful doses before breakfast and at night or it may be served on vegetables and salads. If one or two tablespoonfuls are taken at night and before breakfast, it may act as a laxative. In many cases, however, this oil is completely absorbed in the small intestine and hence there is none left to lubricate the passage for the food mass. When vegetable oils do not prove satisfactory, mineral oils may be substituted. These oils have absolutely no fuel value and are not digested in the intestinal canal but mix with the fecal mass, softening it and stimulating its passage through the large intestine. There are certain individuals with whom the mineral oils do not act as lubricants and instead of softening the feces and lubricating the passage will slip through the intestinal canal without carrying the feces along.

~Sample Diet Sheets.~--The following menus are suggested for the use of individuals suffering with chronic constipation:

BREAKFAST

7 A.M. Orange juice and water.

8 A.M. 1 bran muffin with honey and cream. 1 or 2 slices of bacon. Whole wheat biscuits. A cup of coffee, cereal coffee, or hot milk (not boiled).

LUNCHEON

1 P.M. Casserole of beef made with lean beef. Turnips and potatoes. Graham bread or muffins and honey or preserves. Milk or "hot water" tea.

DINNER

Tomato bouillon. Roast lamb. String beans. Potatoes baked with jackets on. Celery salad, dressed with plenty of oil and lemon juice. Prune jelly with whipped cream.

BREAKFAST

Prunes and figs cooked together. Slice of ham with 1 soft-cooked, poached, or scrambled egg. Whole wheat or bran biscuits. Coffee with cream and sugar.

LUNCHEON

Vegetable soup. Pork and beans. Boston brown bread. Baked apple (skin eaten). Oatmeal wafers.

DINNER

Roast beef. Spinach or cauliflower served with butter sauce. Cold slaw. Pineapple jelly (pineapple left in), whipped cream, or Date and fig pudding.

AUTO-INTOXICATION

Auto-intoxication is a condition produced by the absorption of the decomposition products of food in the intestinal canal.

~Absorption of Toxins.~--As a rule the condition occurs in individuals suffering more or less from constipation which may be due to errors in diet or a lack of tone in the intestines, giving rise to a sluggishness in the peristaltic movements in this region of the alimentary canal. In certain individuals the liver is more or less sluggish, or in some way fails to do its regular work of detoxifying the products of metabolism brought in by the blood stream, in which case these toxins are reabsorbed into the system and induce a condition known as auto-intoxication.

~Care of Bowels.~--As a rule the patient has more or less fever, nausea and at times vomiting. The head aches and the abdomen may be distended by the formation of gas in the intestines. The treatment is like that used in the majority of intestinal disorders. The bowels are emptied by means of soapsuds or salts and glycerin enemas. Certain physicians recommend an enema made with equal quantities of milk and molasses, with enough hot water added to make a thin, warm solution. Care must be used in preparing this flatus enema on account of the danger of curdling the milk with the acid in the molasses and the hot water. If the solution should curdle it must be discarded and a fresh solution prepared. A flatus enema containing salts, glycerin, and a few drops of turpentine is also valuable in removing the gas formed by the action of the putrefactive bacteria upon the unabsorbed food mass. This enema must be given "high" so as to reach the spot in the colon where it may efficiently do its work.

~Dietetic Treatment.~--The diet may consist of fluids for the first few days, or as long as the fever continues. ~Buttermilk~ is probably the best fluid food to use under such conditions, since it not only nourishes, but likewise furnishes lactic acid bacteria which aid in the destruction of the more harmful bacteria, especially numerous under the conditions just mentioned. When whole milk is given it is best to peptonize it. Well-strained meat broths may be given occasionally to vary the diet and albumenized orange juice or orange juice in carbonated water may also be given once or twice daily during the febrile period. After this, the patient may have well-cooked cereal gruels. These may be dextrinized with vegetable diastase (Taka diastase) if necessary. A return to normal diet is made gradually to prevent a return of the trouble. The patient should be advised against overeating, and eating highly seasoned or indigestible foods.

~Convalescent Diet.~--The diets recommended for use during convalescence from other intestinal disorders may serve here, reducing, however, the allowance of meat, since meat proteins are particularly susceptible to attacks of putrefactive bacteria.

~Dietary Precautions.~--After the body has returned to its normal state, the patient must keep in mind the danger arising from constipation and intestinal putrefaction. The following menu is given as a guide to aid the individual in selecting a diet which will in a measure assist in preventing future attacks of intestinal putrefaction and auto-intoxication:

7 A.M. 1 glass of water with orange or lime juice.

BREAKFAST

8 A.M. Stewed prunes or figs. Cereal and cream. Buttered toast. Crisp bacon. Coffee.

LUNCHEON

Vegetable or tomato soup. Green vegetables such as cauliflower, greens, or tomatoes; or Baked dishes such as macaroni and cheese, scalloped macaroni and tomatoes; or Baked potatoes, or potatoes _au gratin_, or stuffed tomatoes with rice. Stewed fruit or fruit jelly. Sponge cake with simple sauce. Junket. Toasted crackers or bread.

DINNER

Milk soup. Cream of spinach, celery, peas, or tomatoes. Baked eggs, cheese souffle or nut loaf. Tender green peas, cauliflower, spinach, boiled or creamed potatoes, well-boiled rice. Fruit, vegetable, tomato, or cheese salad. Simple dessert, such as cottage pudding with simple sauce, fruit pudding, prune whip, or frozen desserts; ice cream or water ices; or Cheese and crackers. Coffee.

SUMMARY

DIARRHEA

~Character.~--Acute or chronic, accompanying many pathological conditions, especially in children in whom diarrhea in any form must be given immediate attention.

~Causes.~--Errors in diet, polluted water or milk, ptomaines, bad hygiene, and certain drugs.

~Bowels.~--The stools vary in number from three to twelve a day. They may be greenish yellow in color, containing mucus and particles of undigested food and, in prolonged cases, blood.

~Treatment.~--Rest in bed and total abstinence from food for from twenty-four to forty-eight hours. Salines are usually given by mouth or by rectum, but this is left to the discretion of the physician. Very little water is given by mouth during the period of total abstinence. Thirst is relieved by bits of ice, and enemas are given if necessary.

~Administration of Diet.~--When acute symptoms have disappeared and the stools are becoming more normal in character and number, a fluid diet of from four to six ounces is administered every three or four hours or oftener if patient is very weak. Brandy may likewise be given in cases in which exhaustion is marked.

~Dietetic Treatment.~--Concentrated foods of the simplest character and only those known to agree. Proprietary infant or invalid foods, except malted foods, which exert a laxative effect; among those found to be good may be mentioned Mellin's Food, Imperial Granum, and Racahout.

~Foods to Be Avoided.~--Fatty foods; pork, veal, and shellfish; all foods that are subject to fermentation in the stomach or intestinal tract (sugar).

~Foods to Be Limited.~--Fluids, soup, beverages, etc., because they impose more work on the intestines.

ENTEROCOLITIS

~Seat of Inflammation.~--Lower intestine and colon.

~Differentiating Characteristics.~--More mucus and blood in stools; greater prostration; greater rise of temperature; and less anemia than in chronic enteritis.

~Dietetic Treatment.~--Practically the same as in other diarrheas.

DYSENTERY

~Characteristic Symptoms.~--Acute and spasmodic pain, tenderness and distention in the bowels, moderate fever, straining and a constant desire to defecate, small stools containing blood and mucus, loss of weight and marked anemia when condition becomes chronic.

~Treatment.~--Rest in bed absolutely necessary; the use of the bedpan made obligatory; soreness relieved by hot turpentine stupes or spice poultices.

~Dietetic Treatment.~--No food for a period of from thirty-six to forty-eight hours, after which fluids and the regime recommended in acute diarrhea are advisable. In chronic dysentery the diet is practically the same. The extreme exhaustion and anemia accompanying these conditions make it necessary to increase the diet carefully but soon to offset as far as possible the devastating effects of the disease.

APPENDICITIS

~Treatment.~--Confinement to bed is absolutely necessary while acute symptoms prevail. The life of the patient may depend upon the care with which this "quiet" period is carried out. No food should be given for twelve or more hours to enable the physician to make a proper diagnosis and to allow the intestinal tract and appendix complete rest from the irritating effects of food passing down the canal.

~Dietetic Treatment.~--~Acute Stage:~ Total abstinence for a period, after which fluids as given in other acute intestinal disorders. No solid food until acute symptoms have subsided; then a gradual return to normal.

~Convalescence.~--When tenderness in right side has disappeared, the return to a normal diet is made gradually. Gelatin, soft eggs, soft toast, fine cereal gruels, well-cooked rice, well-baked white potatoes, tender rare beefsteak or lamb chops, the breast of chicken, sweetbreads, and brains are recommended.

~Relapse or Recurring Appendicitis.~--The patient must be warned against eating indigestible foods or any kind of foods liable to cause constipation; also against overeating or eating when over-heated or over-tired. One attack predisposes to another, hence the above precautions are necessary to prevent the condition from becoming chronic.

CHRONIC CONSTIPATION

~Causes.~--Improper foods, indoor occupations leading to a lack of fresh air and exercise, bad hygiene, certain drugs, such as cough sirups, etc., containing opium in some form, constant use of cathartics and enemas to move the bowels, heredity.

~Dietetic Treatment: Foods to Be Avoided.~--Highly spiced foods must be avoided on account of their astringent qualities, too concentrated foods because they fail to furnish the necessary bulk without which the waste matter cannot pass out of the body at a sufficient rate of speed to prevent putrefaction taking place in the intestinal tract.

~Foods Stimulating Peristalsis~ on account of their bulk: Bulky foods, such as vegetables, cabbage, turnips, cucumbers, spinach, beans, celery, lettuce, etc.; cereal foods containing a high percentage of bran, bran bread and cookies, fruits such as raisins, prunes, figs.

~Foods Acting as Stimuli to Intestinal Movements~ on account of their acid content: Limes, oranges, apples, prunes, figs, raisins, most fruit juices (blackberries excepted), rhubarb, tomatoes, cauliflower, spinach, onions, honey, and molasses; senna leaves likewise have a distinct action upon the peristaltic movement of the intestines, hence are included here.

~Precautions.~--Emphasis should be placed upon the dangers of (1) overeating any of the foods indicated in the above list and thus bringing about conditions more dangerous in result than the original disturbance; (2) the taking of drugs to move bowels on account of the ease with which the habit is acquired and the consequent inability of the bowels to move without such whips; (3) the taking of too little water, thereby allowing a too concentrated condition of the food mass and a consequent accumulation of substances which inhibit peristaltic action.

~Use of Fats and Mineral Oils.~--Olive and other vegetable oils, if not completely absorbed, are advised on account of their lubricating effects. The same can be said of the mineral oils which have no food value but in many cases furnish the lubricant necessary in certain individuals suffering from sluggish intestinal peristalsis.

PROBLEMS

(a) List the food used in the treatment of enterocolitis; outline the method of administering the diet.

(b) Formulate a convalescent diet for diarrheal cases.

(c) List the foods used in chronic constipation; list the avoidable ones.

FOOTNOTE:

[94] Malted foods are contraindicated, as malt exerts a very laxative effect.