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Enteral Disorders of Childhood

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EHTERAL DISORDERS 07 CHILDHOOD*
J* C* Hogarth*
ProQuest Number: 13849762
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ENTERAL DISORDERS 0? CHILDHOOD,
INTRODUCTION*
The disorders classified by the Registrar General as
"Diarrhoea and Enteritis" have been the subject of much investigation
but there can be few about which so many contradictory statements
have been made*
HISTORICAL REVIEW.
Diarrhoea at teething was observed by Hippocrates*
Aretaeus in 100 A*D. described cholera infantum as a most acute
illness associated with vomiting and diarrhoea, and states that the
condition tends to occur in hot weather*
In 852 A*D*, Rhazes notes
the connection between teething and diarrhoea*
Begallardus (1492)
also remarks on this association and condemns milk contamination*
In 1565, de Vallenbert again brings out the association
between teething and diarrhoea.
In 1653, Pewell stated that one
of the most important causes of enteritis was milk contamination and
advised avoidance of milk for a day as treatment of the condition*
Harris in 1647 had already stated that enteritis was most common
from July to September and that he thought the heat of the season
weakened the infant.
The Heberdens in 1710 were of the opinion
that too much or unsuitable food could be held responsible in many
cases and emphasised the importance of careful regulation of the
infant’s diet.
They considered tincture of opium to be a most
valuable adjunct to treatment.
Benjamin Rush (1745) was the first to write anything like
- 2 a systematic account of the condition and he uses the term cholera
infantum to describe the form of enteritis which was most common in
hot weather.
He noted that the most susceptible ages were from
two weeks to two years.
His description of the illness shows
that it was almost exactly the type which is later described as
acute choleraic enteritis.
He is very strongly of the opinion
that dentition aggravates the condition.
He considers that no
remedy is reliable.
Vogel (1866) was the first to draw attention to the fact
that enteritis is most common in artificially fed infants.
He
recognises the association with teething.
In contra-distinction to many of the previous writers,
Goodhard (1885) believes "summer diarrhoea" to be easily curable by
simple means.
He makes the important statement that any measures
directed towards the improvement of hygiene will reduce the incidence
of acute diarrhoea.
Smith (1884) recognises three types of enteritis.
(a)
A simple non-inflammatory type due to improper feeding and
teething.
(b)
An acute inflammatory type (entero-colitis) which
is commonest in hot weather and which affects bottle-fed babies.
He makes the important statement that the condition is infectious.
(c)
The third type he calls choleraic diarrhoea which he believes
can be associated with all the above-mentioned factors.
West (1884) attempts a classification into simple
catarrhal diarrhoea and dysentery.
He found that these conditions
- 3 were commonest in children of six months to two years of age and
that they occurred mainly in the months of August, September and
Oetober•
Prom the time of Hippocrates then up to the nineteenth
century, certain facts came to be recognized, namely, that
enteritis was a disease of infants most of whom were artificially
fed which tended to occur in the hot months of the year.
The
association of the disease with dentition, faulty diet, imperfect
hygiene and towns was noted.
(59, 141, 154, 156, 166.)
CLASSIFICATIONS.
The classifications of the enteral disorders of childhood
are many and varied, reflecting the difficulty found in assessing
the different entities.
The first classification was based upon
the clinical aspect of the various forms of enteral upset, upon
symptomatology, the term cholera infantum being one of the
designations used.
Then, later, when it was found that this
scheme was not satisfactory, a further attempt at classification on
a pathological basis was made upon what was supposed to be the
anatomical site of the lesion.
came to be introduced.
Thus, such a term as ileocolitis
It was soon recognised, however, that there
was apparently no relationship between the morbid anatomy and the
various forms of enteritis.
The next phase coincided with the
increase in bacteriological knowledge which led up to the
recognition of the dysenteric group.
This classification was
based upon the various micro-organisms which, from time to time,
- 4 were thought to be implicated.
This point will be discussed more
fully later when the question of etiology is debated.
I can now
state briefly that no one organism has been definitely isolated
which could be shown to cause the important and most deadly form of
enteritis.
Further classifications were based upon the theory that
imperfect diet and parenteral infections were potent causes.
In
fine, it may be said that a certain amount of progress was made
because from the main bulk of cases of enteritis could be separated
those due to known bacteria, to dietetic errors and to the presence
of parenteral infections.
There still remains one group of cases
of acute enteritis, the most deadly type by far, which has in turn
been included in each of the categories enumerated above and it will
be to this group in particular that I shall refer in succeeding pages,
under the title of "Acute enteritis of uncertain etiology".
Upon
examining suggestions as to the etiology of this last type of
enteritis, I found that the bacteriologist and Tbiochemist vied with
each other to produce a multitude of bacteriological and biochemical
causes while the clinician, as inferred above, remained faithful
to two main theories, that of a dietetic cause and that of a parenteraL
cause.
Among the organism v/hich have been incriminated in the last
twenty years are S.Morgan 1, B.proteus, unnamed gram negative
bacilli,
anaerobes, B. MacConkey, B. paracolon, abnormal types of
B. coli and various fungi.
The typhoid, paratyphoid, dysentery and
salmonella organisms have been purposely omitted from this list
because, although until fairly recently they were thought to be
- 5 implicated, as causes of acute enteritis of uncertain etiology, there
is a growing literature to show that the disorders caused by these
organisms are quite separate clinical entities (8,60).
It is obvious upon surverying this formidable list of
organisms that the bacteriology of acute enteritis of the type to
which I am now referring is far from being in a satisfactory state
especially when it is remembered that the majority of the organisms
mentioned above can be found in the stools of children who are
apparently well and who have no history of any intestinal upset*
The biochemist has been nothing if not ingenious in
providing causes for this severe illness*
The biochemical theories
vary from those of diminution of gastric secretion of hydrochloric
acid, increase in the alkalinity of the contents of the upper levels
of the small intestine and increased permeability of the intestine
to those somewhat obscure metabolic disorders variously ascribed to
changes in air temperature and subsoil temperature.
To do the
biochemist justice, however, it may be said that unquestionably his
work
on the body fluid and cell changes in dehydration and starvation
have
been of the greatest assistance to the clinician in his
treatment of cases of enteritis*
(5, 6, 8, 19, 20,21,22,2-3,29,30,
31,32,33,34,39,40,43,48,54,60,62,63,70,71,72,73,77,79,80,81,83,84,
85,86,87,78, 90,92,94,95,103,104,106,109,110,113,118,119,120,133,136,
138,142,143,144,145,146,147,157,162,165.)
So far
parenteral cause
as the clinician’s theories of a dietetic or
a
of this acute type of enteritis is concerned it is
my belief, speaking from personal experience, that although there
- 6 are definite clinical grounds for their inclusion as causes of
certain forms of enteritis, they play no part in the production of
acute enteritis of the deadliest type and, as such, they have been
given undue prominence in the literature*
I think that a survey
of the points indicated above will show ample justification for the
qualification "of uncertain etiology."
GENERAL ETIOLOGICAL FACTORS.
To return to the etiological factors which have a
bearing upon the whole group of enteral disorders of childhood,
we are upon much surer ground when we discuss the Public Health
aspect.
It is agreed that the steady reduction in the incidence
of, and to a lesser extent the mortality from "Diarrhoea and
Enteritis" is directly due to the introduction of legislation
improving housing and sanitary arrangements in general with a
consequent reduction in the number of flies and of propinquity.
Other advances having a bearing on this reduction are the
provision of centres at which mothers are taught safe methods of
feed preparation as well as general cleanliness in the running of
their homes.
The careful supervision of the production of cow’s
milk, the general use of pasteurisation and the manufacture of
almost sterile dried milks have also played a large part.
I believe
that the greatest reduction in enteral disorders has been in the less
fatal types which, in my opinion, are due to faulty feeding and to
parenteral causes and which are most easily influenced by public
health measures.
Reduction is apparently not taking place in the bacterial
forms of enteritis and dysentery of the Sonne type especially is
becoming much commoner in London.
This is no doubt in part due
to better diagnosis but there is an actual increase also.
See Table 1.
Table 1.
Taken from Registrar Generali Returns.
No of Cases of Dysentery notified ins1928
1929
1930
1931
1932
1933
1934
683
573
538
809
924
783
763
Deaths 155
98
97
116
133
92
103
No.
1935
1936.
1,177 1,333
116
87
I believe that acute enteritis of uncertain etiology has
remained almost stationary in its incidence for the following
reasons.
While the diminution in the number of deaths from
"Diarrhoea and Enteritis”, for example from 5,394 in 1926 to
3,220 in 1936, appears great, a rather false impression is given.
It must be admitted that there is a great reduction in the incidence
of enteral disorders.
Conversation with any clinician in a
children*s hospital will confirm this but the figures regarding
deaths are apt to be misleading.
When it is remembered that the
birth rate (Rate per 1000 population) in adimiriishing population has
fallen from 17.8 in 1926 to 14.8 in 1936, it is realised that a
smaller infant population is at risk now than even such a short time
ago as ten years.
In this case then the reduction in the number of
deaths is partly a reflection of the diminishing birth-rate and the
apparent reduction is not so great as would be supposed.
This is
seen when the infant mortality figures (Deaths per 1000 live births)
- 8 are considered, namely 7*77 in 1926 and 5*32 in 1936#
DETAILS OF THE PRESENT INVESTIGATION.
After a survey of the facts which have been set out
above and with the knowledge that my own clinical observations
of cases of acute enteritis showed material differences from the
majority of recorded observations, certain questions emerged.
(1)
What were the reasons for the differences of opinion?
(2)
Might it not be possible that the clinical basis which rau3t
form the foundation of every investigation was at fault?
In other
words, was the true clinical state of affairs being lost in a maze
of complex biochemical and bacteriological research?
(3 )
In close association with the last question, had the reduction
in the incidence of diarrhoeal upsets of the less fatal types brought
to light any new clinical entity which until recently had been
obscured?
Obviously the last and most important question could
only be answered if a thorough clinical investigation was carried
out.
Fortunately at the time, two and a half years ago, when
these questions presented themselves, the opportunity to proceed
with such an investigation arose.
The London County Council, in
view of the increasing difficulty in dealing with cases of enteral
disorders in children in general hospitals, principally on account
of the increasing number of ward outbreaks, decided to admit such
cases to their isolation hospitals.
The various medical officers
- 9 of health circularised the local practitioners and hospitals
notifying them that arrangements had "been made to provide
accommodation in the local isolation hospital for cases of
enteritis in children.
At first it was considered that open wards should he
set aside for the reception of these children hut, after strong
representations from the superintendents of the isolation hospitals
who fully appreciated the danger of such a procedure, it was
decided to adapt a separation ward for this special purpose.
The
Eastern Hospital was the first of the isolation hospitals to do
this.
A ward containing nineteen separate single hedded cells and
one dayroom containing two cots was redesigned in order to deal
with the difficulties which it was felt might arise.
Overflow
cases were to he admitted to the ordinary separation blocks and
nursed in separate single-bedded cells.
The details of nursing
technique, kitchen accommodation, methods of food preparation and
the various problems which arose will he considered later.
Although the first intention was to admit to this special
ward only such cases as were certified as "Gastro-enteritis"
"Acute Enteritis" or "Zymotte Enteritis", it was soon found most
convenient to admit all
than to
cases of enteral disorder in children rather
distribute them throughout the hospital.
Thus those ca&es
certified as "Dysentery" were sent to the special ward also.
had the
This
added advantage that one medical officerdealt with all such
cases.As far as possible the children
of five
years of age and
under were admitted to the special ward while those children of
- 10 over five years of age were sent to the overflow ward.
This being
the case, it was decided to study the whole range of cases of
enteral disorder admitted to these wards.
This necessarily meant a considerable increase in the
scope of the investigation but it was felt that a complete inquiry
would ultimately be of more value than the study of a limited
number of cases of one particular type.
With these introductory remarks, I shall
a description of the objects of the investigation,
now proceed to
j
the factsbrought
to light and the conclusions reached.
MAIN OBJECTS 0? THE INVESTIGATION.
(1)
1
To study clinically all types of enteral disorder of childhood
admitted to the special wards and to endeavour to throw fresh
!
light upon the various forms of enteral disorder.
(2)
To try to improve upon existing methods of diagnosis at the
i
|
bedside and to form a simple routine for this purpose.
j
(3)
j
To assess the value of the various forms of treatment which have
been suggested and to try any fresh methods that might be indicated
j
by the clinical findings.
j
(4)
.
To evolve the safest possible method of nursing, in hospital,
a number of young children suffering from a variety of enteral
disorders.
CLASSIFICATION.
It was obviously necessary to have a scheme of
- 11 classification to work upon and that which I used was based upon
existing bacteriological knowledge and upon personal experience
of ward outbreaks of enteritis during the measles epidemic of 1936.
It was not found necessary to revise this classification in the
light of subsequent experience and it is probably as complete as
one upon such a basis can be.
The cases are first divided into two main groups, the first beingsA.
Non-infective Enteritis.
This is sub-divided into three sub-groupss(a) Dyspeptic Knteritis.
This term is intended to cover
the enteral upsets caused by faulty feedihg or
unbalanced diet which may give rise to such donditions
as coeliac disease, carbohydrate dyspepsia and fat
dyspepsia.
Another type included under this
heading is that associated* with dentition.
(h) Mechanical Enteritis. Under this term come all those
cases of enteritis associated with such conditions
as pyloric stenosis, intussusception
and worms.
(c) Symptomatic Enteritis. Corresponding to the type
commonly associated with a parenteral infection such
as otitis media, mastoiditis or pyelitis, to
mention only a few.
The second group is termed:B.
Infective Enteritis.
This group is further sub-divided into two sub-groups:
(a ) Infective Enteritis of known etiology.
This was intended to include all enteritis due to
a known micro-organism such as the dysentery organisms
Shiga, Flexner and Sonne, the typhoid and
para-typhoid organisms and organisms of the Salmonella
group.
- 12 ()
Infective Enteritis of uncertain etiology•
This heading designates the type of enteritis which
may he described briefly as that type in which no
known causative organism can be incriminated,
no parenteral, dyspeptic or mechanical cause
can be found but which takes the form of two
completely different clinical entities which
have been designated:• 1.
2.
Acute Toxic Enteritis;
Acute Choleraic Enteritis.
The inclusion of these two types in the infective
group was based upon experience of outbreaks in wards when the
infectivity became obvious and the two types were clearly
distinguishable*
Finally came a group of cases which could not definitely
be included in any of the above mentioned categories.
These were
termed simply
C.
Unclassifiable types of enteritis.
GENERAL PRINCIPLES OF THE INVESTIGATION.
The investigation of cases was originally planned to
extend over a period of two years but, although this report is
based upon the results of this two years’ survey, so many points
came to be raised, as will be seen from what follows that it may
have to be continued over a period of several more years.
The
maximum age limit was set at fifteen years and the total number of
cases investigated was 275.
All these cases were admitted directly
from outside, internal transfers being excluded as they were mostly
- 13 suffering from some other complaint with consequent obscuring of
the clinical picture*
The routine examination of each case was
very complete and included, besides the necessary complete physical
examination, a thorough search for parenteral infections*
The parenteral infections which were particularly looked
for were otitis media or mastoiditis, catarrhal conditions of the
upper respiratory passages and pneumonia, as is so strongly stressed
by Graham (60).
The urine was examined for any abnormal constituents
such as pus cells and organisms.
The faeces were tested for
abnormal organisms on two separate occasions at an interval of three
days.
In the later cases serological examination was done when
possible.
In addition, mothers were closely questioned about diet
to find out if there was anything wrong with the food or its method
of administration.
The reasons for this investigation and details of the
ideas behind
it being stated, the next step is to consider the findings.
DISTRIBUTION
OF THE 275 CASES USING THE CLASSIFICATION DESCRIBED*
A.
Non-infective Enteritis.
Total ■
(a). Dyspeptic Enteritis*
No.
=
15.
(b ). Mechanical Enteritis.
No.
®
7•
(c). Symptomatic Enteritis. No.
B.
35.
Infective Enteritis.
13.
Total r 198.
(a).
Enteritis of known Etiology.
No.
(b).
Enteritis of uncertain Etiology. Total s 109.
No. r
-
89.
1.
Acute Toxic Enteritis.
32.
2.
Acute Choleraic Enteritis. No. = 77.
|
- 14 0.
UNCLASSIEIABLE TYPES OF ENTERITIS.
Total r 42.
GENERAL ETIOLOGICAL FACTORS IN ENTERAL UPSETS IN CHILDREN.
Before passing on to a detailed analysis of the cases,
it is best to deal now with certain etiological factors which have
a bearing on all forms of enteritis.
Of these the most important
are feeding, social conditions, climate and Public Health.
Feeding.
It is generally agreed that enteritis is usually found
in children who are artificially fed. (29, 47, 76, 132, 153).
The present series of 275 cases bears this out as only
three of the children were breast fed and three had combined feeding.
The remaining 269 cases were either fed on dried milks, cowfs milk or
in the case of the older children on "the run of the house."
The
relationship of breast feeding to the occurrence of enteritis is
very difficult to assess.
It is suggested that children on the
breast are much less liable to contract enteral disorders and this
is certainly borne out oy the figures of various authors and by
those of the series under discussion.
The reasons for this
comparative immunity of the breast fed infant from the various forms
of enteritis must be several.
Breast milk is the physiological
food for the infant and children so fed are less liable to develop
the dyspeptic forms of enteritis.
Catarrhal children are usually
- 15 bottle fed.
There is less risk of contamination of the breast
milk with dust, dirt, pathogenic organisms or toxins with a
consequent reduction in the incidence of infective enteritis in
such children.
A further possibility is that immunity may be
passed from the mother to the child in the milk.
This seems
possible in the enteritis of uncertain etiology as the disease is
not recognised in adults and is rare in breast fed infants.
(3,8,104,115).
SOCIAL C017DITI0DS.
the various forms of enteritis are
commonest among children of the poorer classes living in over crowded
and unhealthy surroundings.
All my cases came from the poorest
class and Findlay and haitland-Jones from wide experience in private
practice, state that enteritis is uncommon among private patients.
(47,80,104).
CLI&ATE.
Climatic changes seem to have some bearing upon
the epidemiology of certain forms of enteritis.
The bacterial
forms tend to occur in the warm weather of the late summer while both
types of enteritis of uncertain etiology are, in my experience
commonest in the winter and autumn months.
So far as London is
concerned "Summer Diarrhoea” in a severe form has disappeared.
Christie informs me that during the warm spells of the summer of
1939 ther6 was a considerable number of very mild cases of diarrhoea
in 7/illesden.
Done of these cases was of a serious nature and all
responded to simple dietetic measures.
to an end when the warm spells finished.
admitted to my wards. (24).
The outbreaks rapidly came
Done of these cases were
- 16 C H A P T E R
A.
1.
NON-INFECTIVE ENTERITIS*
Total number » 35.
This type forms a small part of my series (12*7$) and several
explanations for the smallness of numbers suggest themselves.
A
steady decline in the frequency has been recorded during the past
forty years.
The public are now educated to recognise that
enteritis may be due to faulty feeding and digestive upsets and to
seek early advice at Naternity and Child Welfare centres where the
children can receive out-patient treatment.
The family doctors
are now better able to give advice on the proper control of diet.
As the result of these improvements only the acutely ill patients
need in-patient hospital treatment.
The paucity of cases belonging
to the mechanical and symptomatic groups cannot be explained in
this way.
The mechanical type would not ordinarily be diagnosed as
enteritis but would be diagnosed and treated according to the
mechanical defect.
Thus cases of pyloric stenosis, intussusception
and worms v/ould be sent to general hospitals.
type the explanation is more obscure.
As for the symptomatic
'While it is likely that some
of these cases are sent to general hospitals for the treatment of
the parenteral infection, which is considered to be the cause of the
enteritis, I think the main reason is that although diarrhoea is
often associated with parenteral infections, especially those of the
respiratory tract, it is seldom of a severe nature.
The association,
as I shall try to prove later, has been over-emphasized in the past.
- 17 (a).
Dyspeptic Enteritis.
Only fifteen cases of this type (5*5$ of the total)
were admitted during the two year period;
ten were due to
dietetic errors and five were associated with dentition*
These figures support Sraellie’s thesis who considers the
incidence negligible (153).
There were two deaths in
this group, one a child of one month who had been taken
off the breast for no apparent reason and fed on Ostermilk,
the other, an infant of fifteen days, who had also been
taken off the breast after ten days.
Both were admitted
in a state of inanition from which there could be little
hope of recovery.
In neither case was there any evidence
of a parenteral infection and no abnormal organisms were
found in the stools.
Permission for post-mortem
examinations was refused in both cases.
Details of ages
and duration of illness of the remaining eight cases are
given in the accompanying table.
(Table 2).
Seasonal
incidence was unimportant as the cases were regularly
distributed throughout the two years.
Table 2 . Table showing age and sex distribution and duration of
illness of cases of dyspeptic enteritis in children
surviving.
Case Ho.
Ages.
Sex
Bays of
Illness
1
.
2.
9/12
7/52
F
F
3 days
7 days
3.
11/52
F
8 days
.
7.
8.
16/12
2/12
8/12
6
4.
5.
3/12
9/12
F
F
F
3 days
2 days 7 days 2 days
1C days
Average duration of illness =
5.25 days.
F
M
- 18 The foregoing figures show that the illness is mild and short-lived
if treated in the early stages.
It is important to question the
mother closely to find the dietetic error.
This is often gross
and simple correction has the desired result within a very short
time.
This is in agreement with the opinions of Graham and
Maitland-Jones (60, 104).
All ray cases developed diarrhoea after a sudden changs
of diet.
Six of the children became ill a day or two after being
taken off the breast and put on artificial feeding.
The remaining
four developed diarrhoea shortly after a change from the food to
which they had been accustomed.
One child, eight months old, had
been fed on cakes.
In the five cases where enteritis was associated with
dentition the illness was milder than that due to faulty feeding.
The ages, sex, distribution and duration of the illness are shown
in the following table (table 3).
Table 3 .
TABLE SHOEING AGE AND SEX DISTRIBUTION AND DURATION
OE ILLNESS OF CASES DUE TO DENTITION.
No.
1
2
Age
6/12
6/12
Sex
Duration of
Illness.
P
K
3
7/12
M
3 days 3 days 2 days
4
5
9/12
7/12
M
M
4 days
5 days
As soon as the tooth erupted the diarrhoea ceased.
The only
treatment necessary was careful supervision of the diet and attention
to mouth toilet.
- 19
(b). Mechanical Type of Enteritis.
Seven cases fell into this group and there was one
death.
The fatal case, a child of nine weeks, had
intractable diarrhoea with occasional vomiting and abdominal
distention.
examination.
No other abnormality could be found on
The general condition rapidly became worse
and death occurred in three weeks.
Post-mortem examina­
tion revealed a hypertrophic pyloric stenosis which was
the probable cause of the enteral upset.
Of the remaining six cases three were due to
constipation-pseudo-diarrhoea - two to round worms andone
to intussusception.
The latter case was detained long
enough to make a diagnosis and then was sent to a general
hospital for operation.
The response of the other five
cases to treatment was good.
Regulation of the bowels
in the three constipated children and treatment for round
worms in the other two soon resulted in cessation of the
diarrhoea.
Of these two groups, (dietetic and mechanical) it may
be said that recovery will take place if suitable measures
are adopted.
Two provisions must be made.
Early treat­
ment is essential when enteritis is due to faulty feeding.
Both cases which died were almost moribund
on admission
while the remainder had only been ill for 3 days at the
qaost.
In the mechanical group the cause of enteritis may­
be of such a nature that surgical treatment is necessary.
- 20 This must "be borne in mind when each case is under
investigation.
(c). Symptomatic form of Enteritis.
Under the designation are placed all forms of enteritis
which are directly associated with an ex-enteral focus of
infection.
It is generally agreed that of these ex-enteral
foci the respiratory system is the most important although
infections elsewhere can be associated with diarrhoea.
While this theory is widely accepted, there are certain
divergencies of opinion of very considerable importance.
The actual mechanism by which the diarrhoea is produced
still remains in doubt.
Various suggestions have been made
and it is possible that they are all partially correct.
Of these I think that swallowed sputum
and the excretion
of toxic through the intestinal wall are probably the two
causes most likely to cover the greatest range of
possibilities (46, 60, 110,).
While the idea of
swallowed sputum may quite well explain the enteral upsets
associated with such conditions as otitis media, tonsillitis
and pneumonia, to mention only a few infections of the
respiratory tract, this mechanism cannot explain the
diarrhoea that may be associated with such conditions as
pyelitis or impetigo.
It is in these conditions that the
theory of absorbed and excreted toxin holds most promise.
Perhaps it may be said in a general way that a combination
of both factors is nearest the truth.
However, the
- 21 -
mechanism by which the enteritis is brought about does
not seem to be subject to such difference of opinion as
the actual association between parenteral infections
and enteritis.
One school of thought, and this is
mainly American, is of the opnion that acute enteritis
is a development of a parenteral infection of which the
most important is otitis media (48, 77, 81, 113, 153).
ThehA,counter to the argument that treatment of such
a parenteral focus of infection is not of great value is
that it has not been thorough enough.
Thus, from America
has come the suggestion that antrostomy should be performed
in cases which do not respond to simple paracentesis.
In
such cases it is suggested that "masked mastoiditis" is the
cause.
The more conservative members of this school,
mainly in Great Britain, while agreeing with the theory
of an ex-enteral cause, have come to the conclusion that
such extreme interference is not justified.
113).
(48, 77, 81,
The other school of whom I shall mention Findlay,
Mitchell and his co-workers, Yambolska and Johnson and
their co-workers (47, 80, 118) are of the opinion that
otitis media, upon which most work seems to have been done,
is not associated specially with enteritis.
Findlay in
his paper shows in a very conclusive manner that, although
enteritis may be associated with otitis media, it may
equally well be associated with any other ex-enteral in­
fection of childhood.
He condemns the practice of
- 22 -
antrostomy and is guarded in his opinion on the merits
of even paracentesis*
The theory of the connection
between the middle ear inflammation and enteritis appears
to be based mainly upon the frequent post-mortem finding
of pus in this situation in fatal cases of enteritis*
Le Mee (92) is of the opinion that the pus found in the
middle ear at post mortem was simply that which had drained
there from the nasopharynx
in consequence of the shortness
of the Eustachian tube in infants but Ebbs did not support
this view because, in his opinion, milk would also gravitate
up the Eustachian tube of the infant if this mechanism was
effective*
He supported the view that otitis was a potent
cause of enteritis and advocated paracentesis at times
followed by mastoidectomy.
Certain other authorities tend
to steer a middle course and believe that extra-enteral
infections can be associated with enteritis but that this
is rarely of
the type associated with toxaemia and intox­
ication (42,
47, 60).Graham has stated that
this type
of enteritis is on the increase but considers that it may
simply be due to greater frequency of recognition.
Personally, when I commenced this investigation I was
uncertain whether ex-enteral infections played an important
part or not and for this reason my clinical examination
always included a thorough search for such a focus as was
advocated so
strongly by Graham. (60).
briefly at this point
I may state
that in no case of acute enteritis
- 23 with toxaemia or dehydration did I find any parenteral
focus of infection at the onset
of the illness.
This
induced me to believe that such
foci when found in
association with acute enteritis either formed part of the
illness, that is to say, that they were part of a definite
clinical syndrome or that they were due to a secondary
infection.
This latter opinion coincides with that of
Mitchell and his co-workers, who state that the source of
the otitis is to be found in the habit of herding children
together and of Maizels and Smith who consider that the
significance of otitis media varies with different patients
(103, 118,),
Of the total of 275 cases which are the subject
of this thesis only thirteen (4,7$) were ascribable to a
parenteral focus of infection.
By this is meant that they
could not be placed into any of
the other categories and that
each case was suffering from an
ex-enteral infection of one
or other kind.
Certain cases cleared up when the patenteral
focus was treated but the majority did so long before cure
of the focus and appeared simply to respond to the careful
hospital regime.
One death occurred of a child of two years of age who
was admitted with a wide spread broncho-pneumonia and died
on the seventh day after admission.
During the seven days
the stools were frequent and green but there was no vomiting.
The youngest child was five months old and the oldest six
years old.
Six of the cases were under one year.
The
- 24 -
six distribution was of no significance, there being six
male children and seven females*
Although the number
is small and the ward conditions were such that only a
limited number of cases could be accepted it is noteworthy
that eight of the cases were admitted between August, 1937 and
January, 1938, and four between August, 1838 and December,
1938.
j
That is to say, the greatest incidence was in the
autumn and winter months at the time when catarrhal con­
ditions are most prevalent*
The table below shows this
I
point*
TABLE 4.
i
TABLE SHOWING SEASONAL INCIDENCE.
OF GASES OF SYMPTOMATIC ENTERITIS.
Year
Jan. Feb. Mar. April May June July. Aug._ Sept. Oct. Nov. Dec.
1937
-
-
-
-
-
-
1
1
1
1938
2
-
-
-
-
-
-
2
-
.
1
2
1
-
1
1
Clinically few of these cases gave rise to anxiety, nine
being assessed as "fair" on admission and four as "poor"*
Included in the "poor11 group was the child who died.
was absent in all cases.
Vomiting
Hone of the cases showed toxaemia
which could be attributed to the enteritis or dehydration.
The
diarrhoea consisted of fairly frequent, relaxed green stools
(average 7 in 24 hours).
10.7 days.
The average duration of illness was
Bacteriological examination of the faeces revealed
- 25 no abnormal organisms in twelve cases and B.Borgan Uo.l. in one
non-fatal case.
The parenteral causes are listed below:Broncho-pneumonia
2
Pertussis
2
Otitis media
2
Acute Rhinitis
1
Tonsillitis
1
Thrush
1
Infected Scabies
1
Impetigo
1
Infection of operation site.
1.
Tonsillectomy
1
2.
Circumcision
1
The response varied slightly.
The pertusis cases which
were in the early stage both cleared up when the disease frankly
declared itself.
The cases with otitis media immediately settled
with the onset of otorrhoea.
These cases following operation
improved with improvement in the local condition as did those with
rhinitis, thrush, impetigo and infected scabies.
As would be
expected the diarrhoea in the two pneumonic cases was of the longest
duration.
The conclusion reached from a study of these cases was that
symptomatic enteritis is not an important complication of the disease
which produces it as it tends to follow the course of the original
disease improving as it improves or persisting as it persists.
The fatal case was obviously a pneumonia death and would no doubt
have terminated in this way whether there had been diarrhoea or not.
I was fully aware that when collecting these figures I had
laid myself open to the criticism that my opinion was based upon an
insufficient number of cases.
Realising that respiratory tract
infection was regarded as the most important ex-enteral cause of
enteritis, I analysed the cases of measles, a disease in which
respiratory catarrh is prominent, which occurred in the 1937
epidemic.
The object was to ascertain if enteritis was frequent
in these cases and if it was of a mild or severe type when it did
occur.
To simplify the analysis, only case reports of children up
to a maximum age of 2 years were considered as that range would,
in my opinion, include the majority of children susceptible to
enteral upsets.
The cases were divided into two groups of 0-1
years of age and 1-2 years of age.
It will be seen from table 5
that the percentage of cases with complications is 21.8 in the
first group and 26.2 in the second group, while the individual
number of complications is 36 and 107 respectively.
complications are given in the same table.
Details of
It will be noticed
that the majority of these belong to the group which can properly
be called parentral infections of the resperatory tract.
TABIS5.
0-1 years
1-2 years.
142
350
No. of cases having complications
31 (21.8#)
92 (26.2#)
No. of complications
36
107
19
54
3
8
13
30
-
5
Total cases of ageB
Details of individual complications
(1)
Otitis media
(2)
Ac. Bronchitis
(3)
Br. Pneumonia
(4) Adenitis
(5)
Tonsillitis
-
1
(6)
Eeroncolosis
-
2
(7)
Stomatitis
-
1
(8)
Abscess
-
5
(9)
Encephalitis
1
1
... ______ ___________
1
Table 6 shows the cases which had diarrhoea at the onset of
measles, during the course of the illness and at the onset and
during the course.
The number of cases which had diarrhoea in the
initial catarrhal stage is fairly high namely 21 (14.8/e) in the
youngest group and 24 (6.8%) in the older children.
The difference
in the percentage incidence between the two age groups is very
obvious and is what would be expected.
The important fact, however,
is the average duration of the diarrhoea, namely 2.8 days in the
younger children and 1.8 days in the older children.
- 28 The course of the disease is taken to he from the secondtenth day.
Those cases which developed diarrhoea during the course
as above defined were 8
the second group.
in the first group and 12 (3.4*) in
The average duration of the diarrhoea once ag£L in
was short, namely 3.9 and 4 days respectively.
A few cases had
diarrhoea at the onset continuing through the course.
As will he
seen from Tahle 6, the average duration was 18.5 days and 14 days.
At this point it should he stressed that the last day of diarrhoea
was estimated upon a strict basis, the appearance of the stools and
the frequency of defecation being absolutely normal at this point.
TABLE 6.
Cases having diarrhoea
0—1 years
Average
Durat ion
1-2 years
Average
Duration
(a) At onset
21 (14.8*
2.8 days
24
1.8 days.
(b) During course
8 (5.7/0
3.9 days
12 (3.4^)
4 days.
(c) At onset and during
Course
2 (1.4*)
18.5 days
2 (0.57/i)
14 days.
Further analysis of the figures reveals the fact that in the
youngest group only 8 cases (5.6*) and in the older group only 5
cases (1.4%) had diarrhoea associated with the onset of a complication
That is to say in the younger group only 25.8* of the cases having
complications developed diarrhoea directly associated with the onset
of the complication, while in the older group only 5.4* of the
complicated cases had diarrhoea in a similar association.
Among
- 29 -
these cases are three deaths, two in the younger group and one in
the older group.
Details are shown in Table 7.
TABLE 7 *
Age
Groups.
0-1 years
1-2 years
Cases having
diarrhoea asso­
ciations with
complications•
8 (5.6#)
5 (1.4#)
Complications with
which diarrhoea
was associated.
Ho.
Broncho-pneumonia
5
(l Br.Bi.
Otitis Media
2
2 (1 Otitis(llastoiditis
Mastoiditis
1
Both with
term. Enter.
Br oncho-pneumonia
3
Otitis media
2
(Tubercle and
1 (Br.Bn. with
(Terminal
(Enteritis.
Deaths•
The facts gathered from analysis of the measles cases along
with the impressions formed from the study of the thirteen cases
which have already been mentioned allow certain conclusions to be
drawn Y-rhich are on a firm clinical basis.
follows.
These conclusions are as
Enteritis of the symptomatic type is a definite clinical
entity but, as such, it is of little significance because in the great
majority of cases it is mild andjof short duration.
It is rarely
the cause of death which is determined by the ex-enteral condition
and rarely by the enteritis.
Ky previous statement that the
diarrhoea subsides before the parenteral infection clears up appears
to be amply justified, although in certain cases it tends to follow
30 the ups and downs of the parenteral infection.
From this, a
tentative suggestion may be made that treatment of the ex-enteral
focus which results in cure will have a similar effect upon the
diarrhoea.
This would amply account for the successes claimed by
supporters of the principle of active treatment such as paracentesis
and antrostoray.
How then can the argument of the other school of
thought be justified?
I believe, and I hope in later pages to
amplify this point, that the conservative school are discussing the
types which I have called the acute toxic and the acute choleraic
types of enteritis and not the true symptomatic type.
In these
forms complications when present are often in the respiratory tract.
The treatment of this form of enteritis by dealing with the
ex-enteral focus is not satisfactory because the main cause of the
illness does not lie in the ex-enteral focus at all.
Thus I believe
that the two entirely different schools of thought can be reconciled.
The association of diarrhoea with otitis media can also be said to
exist but the association is no closer than with any other ex-enteral
focus of infection.
C H A P T E R
II.
INFECTIVE ENTERITIS.
(a )
Qf Tmown etiology.
This title is meant to include all cases
of enteritis from the stools of which known pathogenic organisms can
be recovered or in which a serological examination reveals
agglutination of a known pathogen in a diagnostic titre.
The
pathogens referred to are the typhoid and para-typhoid organisms,
the dysenteric group of which the bacilli of Shiga, Flexner and
Sonne are the best known, the complex and highly populated
Salmonella group and the rare cause of enteritis, the staphylococcus.
In my experience, the principal organism causing diarrhoea is the
B. dysenteries Sonne.
In the series under discussion, out of a
total of 89 cases of enteritis of known etiology 82 (92.1^) were
attributable to this organism.
For this reason I shall confine my
remarks mainly to Sonne dysentery.
Then I shall finally discuss
|
the remaining seven cases.
There has been a marked increase in thenumber of cases of
dysentery notified in England
and Wales in the
last ten years from
440 cases in 1927 to
1,333 cases in 1936. (8)
partly to increasing
interest as suggested by Felsen but it is
|
This may be due
becoming increasingly obvious that dysentery due to the organisms
of Shiga, Flexner and Sonne is endemic
in this country and no
doubt the numbers will further increase as the
examination becomes more widely recognised.
SEASONAL INCIDENCE.
value of serological
(46).
It seems to be generally agreed that the
incidence of dysentery is greatest in the late summer and early
autumn and my figures for Sonne dysentery tend to bear this out
(8).
This is demonstrated in the graph below which shows the
seasonal incidence of my cases.
It will be noted that there is a
definite drop in the
numbers from April toJuly inclusive, in both
1937 and 1938.
incidence from August to October in each year
The
(late summer and early autumn) shows a definite increase while the
j
j
|
- 32 winter months of 1937-1938 have a particularly marked increase.
The figures for November and December of 1938 are not comparable
with those of the previous year which may have been abnormal.
It should be noted that none of the cases under discussion was
involved in an institutional outbreak which might have accounted
for these differences.
The only deduction that can be made is
that the months of April, May, June and July are the quietest so
far as Sonne dysentery is concerned while there is an increase in
incidence from August to October.
In certain years of which 1937
may have been one, there may possibly be an increase in the case
incidence in the winter months.
Yhe increase in cases in the
winter of 1937-38 has not been an accidental one as it continues
over a period of four months.
Although the 1939 cases are not
being discussed in this thesis I may say that the peak of December,
January and February (1937-38) is not repeated in 1939.
TABLE 7.
14
12
10
GRAPH SHOWING SEASONALX
No of
8
INCIDENCE IN 1937-1038
cases.
6
OF CASES OF SCNjfe /
4
DYSENTERY'
'
V
\
\
\
f
'
2
0
/
/
. .....
N _____
)APtIHR<i\Tont l j \ i L < f ] n i K \ s e H l o i T \nl»v IDt c
3"«»o ) f z e > ) Mag
Year in
1937 months
fs e .
»
IS m lo f- f
1)cd
Year in 1938 months.
- 33 IffCUBATIOff PERIOD.
3-7 days.
|
I
}
i
This has been determined by
the study of three ward outbreaks and in each the general outbreak
|
occurred from three to seven days after introduction of the source
of infection.
This has always been an unrecognised mild case.
AGES ATTACKED.
The general impression formed from a study of the 82 cases
of Sonne dysentery admitted in the two year period was that
children under one year of age are relatively immune but this is
not wholly true.
Ward outbreaks have been fairly frequent at
the Eastern Hospital during the years 1938-39
(August) and have
been particularly troublesome in whooping cough wards where
age level is the lowest in the hospital.
j
the
*
j
My opinion is that the
age attacked is mainly influenced by the age df the particular
j
l
|
population at risk.
|
Thus in one outbreak in a whooping cough
ward containing eleven children, of whom three were under one year
of age, one of the three (eight months old) was subsequently shown
to be the source of the outbreak while one of
the remaining two
(six months old) developed the disease.
of a total of ten
Out
children exposed to infection six developed Sonne dysentery.
similar state of affairs was noted in other outbreaks.
A
It would
appear then that an infant is just as susceptible to infection with
B. dysenterise Sonne as any other person.
It can therefore be
stated that Sonne dysentery may attack persons of any age although
it appears to be commonest among children (from the point of view
of hospital admissions) from the ages of 1-5 years.
The graph
I
-34 below shows the age distribution of the cases under discussion.
It must be remembered that this investigation has been confined to
a group of children with an upper age limit of fifteen years so
that the graph only covers this range of ages.
Pyfe records a
milk borne outbreak where 45% of cases were under 20 years of age.
(53).
TABLE 8.
AGE INCIDENCE OP CASES OP
SONNE DYSENTERY 1937-38.
24
20
No of
16
cases. 12
AGES IN YEARS.
METHOD OP SPREAD.
The dysenteries must take their place among
the diseases spread by carriers or mild unsuspected cases.
The
route of transmission will therefore be most commonly water, milk
or food contaminated by one of these carriers or mild cases.
In
each ward outbreak which I have investigated the source of infection
has been an unsuspected mild case but recently I accidently dis­
covered an adult carrier.
with later.
The diagnosis of carriers will be dealt
- 35 CLUTICAL FEATURES.
The onset of Sonne dysentery is abrupt.
The
statement is based upon observations during the ward epidemics which
have already been mentioned.
et al (5l)•
This opinion supports that of Frazer
Generally speaking, in my opinion, Sonne dysentery
is only a moderately severe illness and is only of importance when
it attacks a child already debilitated by some other illness and
even then is often of little consequence.
I have not seen the
severe type described by Graham and mentioned by Frazer and his
co-workers (8, 5l).
This experience is shared by my colleagues
and where more than one case occurs in a ward we no longer isolate
them.
Even the degrees of severity vary greatly in a ward outbreak.
The only sign may be the passage of one or two relaxed stools which
may or may not contain mucus and/or blood and may simply be green
and relaxed.
This latter is especially common in iflfants and may
be the only sign.
The severity varies and in the milder forms
the child has a sLight pyrexia, some colic and passes 5-8 relaxed
stools in 24 hours which, once again, may or may not contain blood
and/or mucus.
In these cases there is often a palpable and
slightly tender colon.
This tenderness is usually most marked in
the right iliac fossa.
The explanation of this, no doubt, lies
in the fact that the lesions are most numerous in the ileum and
upper colon.
The spleen is not palpable.
The diarrhoea in a case
of this type rarely lasts for longer than 48 hours.
In the most
severe type which I have seen the child is lethargic and looks toxic
with slightly sunken eyes and a circum-oral pallor.
The tempera­
ture may be IOOOF with an equivalent ruse in the pulse and
- 36 respiration rates.
The appetite is poor hut thirst is considerable.
The abdomen is slightly distended and tympanitic while the colon
tenderness is more easily elicited than in the type which has just
been described.
This rather ill condition, however, is short­
lived and by the third day after admission the child is sitting up
and looking quite normal while the tympanicity and tenderness have
also disappeared.
It is in this type of case that the presence of
blood and mucus is commonest and although these disappear in 2-4
days the stools may be relaxed and offensive for as many as 9-10
days.
The stools are seldom more frequent than twelve in 24 hours
and it is only rarely that faecal material is not present.
In
my experience vomiting never occurs as described by Moncrieff,
neither have I seen the catarrh of the respiratory tract which
Frazer s b a n d
his co-workers state to be so frequent an accom­
paniment of the infection and my experience bears out that of Fyfe
An occasional case develops a generalised papular urticaria in the
early stages of the illness.
This fact accounted for two of my
cases being diagnosed as scarlet fever before admission to
hospital. (51, 53, 119).
COliPLICATIONS.
There have been no complications in my experience.
■DIAGNOSIS.
As may be imagined the ease of diagnosis varies
with the severity of the case.
Those which have been described
as the severest are the easiest to diagnose while the mildest are
almost impossible to diagnose on a clinical basis alone.
It can
- 37 thus he seen that the notification figures do not in any way
represent the true state of affairs because the infected person may
by ambulant and may never come within the doctor’s province (51,
116, 117).
The presence of blood and mucus in the stools is stress­
ed as being of great importance by certain writers (8, 46, 51, 119).
I can agree with this opinion to a certain extent but it should be
fully appreciated that blood and mucus are not present in the stools I
in Sonne dysentery only and are often absent in that disease.
If,
however, one can exclude such conditions as ulcerative colitis,
tumours of the lower bowel and rectum, haemorrhoids and intussus­
ception the presence then of blood and mucus in the stools is of
definite value in diagnosis and it can be said with some accuracy
|
that the patient is suffering from infective enteritis of known
i
etiology.
I have never seen blood and/or mucus in the stools of
i
!
children suffering from enteritis of unknown etiology.
To demon®
strate the point mentioned above, I would emphasise the fact that
of my 82 cases of Sonne dysentery only 38 (46.3/*) had blood and
mucus in the stools.
]
vVhile there can be no doubt that the diagnosis^
of Sonne dysentery has been rendered more accurate in consequence
of the increase in the skill of the bacteriologist in isolating
the Sonne organism since it was first discovered by Sonne, the
bacteriological examination of the faeces in this disease is at the
best an unreliable method.
I did not fully appreciate this fact
when I first began this investigation but when I was revising the
case papers at the end of my first year’s work upon it I noticed
certain features which brought the point forcibly home to me.
- 38 The figures given below are for the two year period and they
demonstrate the point even better than the figures for one year.
Table 9 shows the original diagnosis of the 82 cases made before
admission.
It will be seen that only 32 cases (39/£) were correctly
diagnosed.
If the term dysentery is accepted, then 53 cases
(64.6/0 were correctly diagnosed before admission.
Twenty two
of the 32 correct diagnoses were based upon the discovery of the
Sonne organism in the stools, the remainder upon the presence of
blood and mucus .in the stools or from their association with known
cases of sonne dysentery.
If the 22 cases are excluded, it will
be seen first how inaccurate clinical diagnosis can be.
Thus of
the remaining 60 cases only 11 (18$) were correctly diagnosed, an
error of
which would appear to be excessive.
The table 9
shows the designations given to these cases.
TABLE 9.
TABLE SHOWING ORIGINAL DIAGNOSIS
OP 82 CASES Off SONNE DYSENTERY.
DIAGNOSIS
No. of cases
Sonne Dysentery
32
Dysentery
21
Enteritis
13
Gastro-Enteritis
13
Diptheria
1
Scarlet ffever
2
TOTAL
82
i
i
- 39 -
If we now consider the clinical findings aided by
bacteriological investigation it will be seen that the position
is very little better.
point.
Table 10 below is used to illustrate this
It will be seen that of the 22 cases found to be positive
before admission, not one was found to be positive after admission
and that out of 82 cases thoroughly investigated after admission,
only 54 were found to be positive, an error of 34.2$
TABLE 10.
STOOL
Before admission
CULTURES
After admission
Number
-
22
Hot investigated
-b
54
Not investigated
-
6
TOTAL
82
It might be argued that inefficient choice of specimens was
at fault but this hardly holds good because each of the two
examinations was carried out upon a rectal swab and a spe cimen of
faeces.
The above findings are of course easily explained because
it is widely recognised that the $onne organism soon disappears
from the faeces (8, 51, 139).
All this raised the question, what
would have been the position pf the twenty two cases which had been
bacteriologically examined in the early stages of the disease if
- 40 this examination had not been possible?
Obviously opinion would
have had to be based upon the unreliable clinical method.
After
reading articles by Blacklock, Graham, Felsen and Ritchie (8, 46,
139) I decided that serological investigation of these cases would
probably be a valuable addition.
Investigations on this subject
have been carried out for the last twelve months and although they
are not yet complete, certain figures are available from which
definite deductions may be drawn.
was the diagnostic titre level.
The first point to determine
With this object in view the
blood of 200 patients convalescent from various diseases was
examined.
five years.
The ages of these cases varied from six months to twentyBriefly the results were as follows.
Only three of
the 200 subjects showed agglutination with B. dysenteriae Sonne in
a dilution of 1 in 20, the remaining 197 samples of serum failed to
show agglutination even in a dilution of 1 in 10.
This disposed
of the idea that it Was necessary to re-examine cases for a rising
titre as any delution of over 1 in 20 could be taken as diagnostic.
This agreed with Sears et al (46, 152).
From serial testing it
was quickly found also that it was useless to examine the serum
before 14 days from the onset of the illness as the Sonne organism
apparently produces agglutinins slowly, as suggested by Blacklock
and Sears (8, 152).
As this preliminary work necessarily took a
long time it was unfortunately only possible to apply the principle
to a few of the cases discussed in this paper.
Of the -six cases
in which no organisms could be found in the stools (Table 10), four
j
were extremely mild and were diagnosed serologically.
The other
two were more ill and presented a typical clinical picture.
Obviously a further point to investigate was whether agglutinins
always appeared and although there is not a large number of cases
from which to quote, it may be said that out of 30 cases investigated
all but one gave agglutination in titres from 1 in 40 to 1 in 680.
Another point which is being investigated is the length of time for
which agglutinins remain in the blood.
Once again, although the
figures are small, principally through difficulty in persuading
parents to bring their children back to a fever hospital, certain
tentative deductions may be made.
Eight cases have been so investi­
gated, two after an interval of two months and six after an interval
of five months from recovery from Sonne dysentery.
The first two
cases, whose serum agglutinated B. dysenteriaie Sonne originally in
dilutions
of 1in 40 and 1 in 160 respectively, now did so in
dilutions
of 1in 20 and 1 in 10 respectively while the remaining
6 did not
agglutinate.
This disposed of Felsen’s theory of the
value of titre levels in assessing the infant’s immunity to Sonne
dysentery.
He considered that lack of agglutinins could be taken
to indicate susceptibility (46).
In Sonne dysentery I take
agglutination to a delution of over 1 in 20 to be diagnostic.
Sears considers that over 1 in 40 should be the diagnostic level
(152).
It will be seen that serological examination of all cases
with a clinical appearance such as has been described vrould be of
considerable value.
I now do a routine serological examination of
all cases of enteritis whatever the clinical diagnosis.
Although
•
so far I have failed to find an unsuspected case of Sonne dysentery
among those which have been classified as enteritis of unknown
etiology I found a few among those placed in the dyspeptic group
in 1939.
I should like againlto emphasize the fact that the above
remarks apply only to the diagnosis of Sonne dysentery.
The
serological diagnosis of the typhoid and para-typhoid groups is
familiar to everyone, the difficulty of assessing the titre rise
having been resolved by the separation of the rtO" and rtH H agglutinins
The position is difficult as regards the diagnosis of the Salmonella
group and of the Shiga and Flexner infections because agglutinins
may be present to a fairly high delution in the serum of persons
who have not had an attack and who are apparently healthy (116, 152).
Fortunately, in my experience, it has been quite easy to recover the
aertrycke, Gaertner and Newport organisms from the stools of such
cases.
I cannot speak of the Shiga and Flexner organisms from this
point of view as I have not seen any of these cases.
However,
during the serological work involved in the investigation of Sonne
dysentery 59 normal children had a complete serological examination
carried out with the following results.
1
case agglutinated B.
typhosus "O" in a delution of 1 in 10
1
case agglutinated B. paratyphosus B in a delution of 1 in 20
5 cases (8.5/S agglutinated B. enteritidis (Gaertner) in a delution
of from 1 in 20 to 1 in 80
4 cases (6.8^S) agglutinated Salmonella group suspension in a
deluti on of 1 in 20
1
case agglutinated B.
flexner (X and Z) in a delution of 1 in 20
5
cases (8.5/S) agglutinated B. flexner (V. W. Y.) to a delution of
from 1 in 20 to 1 in 40.
As all these cases were children it would appear obvious that
the number of agglutinins would be even more varied and in stronger
force in adult serum.
Ritchie (139) considers that agglutination
to a dilution over 1 in 128 for B. dysenteriafe (Flexner), over 1 in
64 for B. dysenteriae (Shiga) and over 1 in 32 for the paratyphoid
organisms to be diagnostic.
The Salmonella group is so constantly
being added to that an opinion as to diagnostic, titre levels is
hardly practicable, a very high or rising titre being required.
Fortunately this trouble does not exist in connection with Sonne
dysentery and in this disease serological diagnosis can be 98j£
correct for the reasons which I have already given.
CARRIERS.
It is only natural that the question of carriers of
B. dysenteriae Sonne should be considered as the ultimate source
of an outbreak.
From the investigations which I have carried out
so far I considered it likely that a carrier might be defined as a
person who might or might not have a history of a previous attack
of Sonne dysentery depending upon the severity of that attack,
whose serum did not show agglutination of the organisms above a
dilution of 1 in 20 but from whose stools B. lysenteriae Sonne could
be recovered.
I have only come across two cases so far which
tended to bear out this theory.
During the routine investigation
of the stools of a woman of sixty-eight years of age who complained
of occasional attacks of abdominal colic sometimes accompanied by
diarrhoea, B. dysenteriae Sonne was recovered.
Examination of the
serum failed to reveal any agglutination of the organisms but she
gave a typical history of an attack of Sonne dysentery two years
previously*
The other case was a child who had been involved in
an outbreak of enteritis in a children’s ward of another hospital
and in the course of a routine investigation of the stools of all
the children in that ward, the Sonne organism was recovered from his
stool.
Once again the serological examination of the patient was
negative but this time there was no history of any previous attack
of diarrhoea.
It is obvious that much more work must be done in
this direction before any definite conclusions can be drawn.
ROUTINE METHOD OF DEALING WITH A WARD OUTBREAK OF SONNE PYjSENTEflf .
The method adopted at the Eastern Hospital on the occurrance
of an outbreak of Sonne dysentery is as follows.
usually explosive, several cases occurring at once.
The outbreak is
Originally
these cases were at once removed from the ward and isolated, to be
followed by any subsequent cases or by any children from whose
stools the organism had been isolated.
This routine has been
changed as the result of experience which has shown the illness to
be very mild in most cases and the infection to have already beai
spread.
Now it is our custom to remove from the ward any child
seriously ill from some other illness leaving the cases of Sonne
dysentery there, each one on strict "barrier nursing" (each child
has his own utensils, gowns, bedpans and the attending nurse scrubs
up before and after giving attention to the child).
Where only
one case is reported on the first day this case is removed and
isolated in the hope, usually a vain one, that no further cases
will arise.
The ward, of course, is closed to admissions until
14 days after the last case occurs or until all stools are negative
on two successive oacasions.
Admittedly this method is not above
criticism but isolation accommodation is limited in all fever
hospitals and usually severely taxed and so far this routine has been
extremely.successful.
ROUTINE INVESTIGATION OF A WARD OUTBREAK.
Stools and rectal swabs are cultured from each child in
the ward on two successive occasions unless the first specimens are
found to grow B. dysenteriae Sonne.
A certain percentage of even
the obvious clinical cases have negative stools.
Fourteen days
from the beginning of the outbreak a serological examination of each
child who was in the ward at the time of the outbreak is carried out.
So far this has been the method of discovering the original sources
of the outbreaks,
their stool cultures being negative.
At this
point I cannot do
better than describe the investigation of an
outbreak of Sonne
dysentery in a small whooping-cough ward.
ward contained 12
cots and 11patients.
On 27th February,
This
1939,
a child of eight months with whooping couch was admitted.
On
28th February this child passed two green relaxed stools.
No other
signs or symptoms were observed.
On the fifth and sixth days after
the introduction of this case into the ward a total of six children
developed clinical signs of Sonne dysentery.
On examination of
stools from the eleven children four were found to be positive, all
being cases which had presented typical clinical signs.
The
remaining seven specimens were negative including that of the child
- 46 introduced into the ward on 27th February.
Fourteen days later
serological investigation was carried out.
In seven specimens
agglutination was found to delutions from 1 in 10 to 1 in 80.
One of these (l in 10) from,a child who had had no clinical upset
was disregarded on the grounds that this titre level was below that
which had already been decided to be diagnostic.
Of the remaining
six five were of children who had been clinical cases of Sonne
dysentery and of whom two had had negative stools
The sixth
(l in 40) was from the child who had been introduced into the ward
on the 27th February and who now could be said to be the cause of
the outbreak.
It will be observed that one case of clinical Sonne
dysentery with positive stools failed to show agglutinins.
already mentioned this case in the discussion of diagnosis.
I have
I have
not, so far, encountered a similar example of this contradictory
state of affairs although, as I have already stated, thirty cases of
Sonne dysentery have been investigated from this point of view.
It will be seen that serological examination forms a necessary part
of the investigation of a ward outbreak.
DIFFERENTIAL DIAGNOSIS.
First of all, conditions such as intussus­
ception, rectal and lower bowel tumours, haemorrhoids and ulcerative
colitis must be excluded.
’S/hen this has been done diagnosis must
be made from the other members of the enteritis group.
This point
is adequately covered in this paper in later pages.
TREATTfFNT-
This is entirely symptomatic, the children being put
013 a light diet until the diarrhoea shov/s signs of abating.
Ample
fluids in the form of water, fruit and glucose drinks are given
Powdered Kaolin has some effect in reducing the offensive odour of
the stools but it is doubtful whether it has any effect in reducing
their frequency.
In the odd case where diarrhoea is really
troublesome, starch and opium enemas are helpful.
PROGNOSIS.
In my experience this is uniformly good as no deaths
have occurred over a period of two years.
In this opinion I am
in agreement with Frazer et al (51) who consider that a fatal issue
is likely only in exceptionally acute choleraic cases or in patients
previously debilitated with other diseases.
this view.
Fyfe also supports
Graham, however, reports a mortality of 22^ with the
qualification that only the severest types were admitted to his
wards.
(53, 60).
POST-MORTEM FINDINGS.
As no deaths occurred in the series under
consideration, I cannot quote from cases in the series.
However
in 1936 a child in a severely debilitated condition following an
attack of severe enteritis of uncertain etiology, was involved in
an outbreak of Sonne dysentery and subsequently died from the
disease•
The post-mo±tem findings were quite typical.
An acute
colitis was present with small superficial ulceration.
The lower ileum was also involved in this process.
The
ulcers were clear cut and had not coalesced and their surface
- 48 was covered with a pale yellow exudate.
in any other organ.
No abnormality was found
This picture fits in exactly with that described
by Boyd and could readily account for the tenderness in the right
iliac fossa which has already been described.
A point of interest
is that, although three stool specimens had been negative, the Sonne
organism was isolated from a swab taken from the base of an ulcer.
This confirms the view expressed by Blacklock (8).
Having fully discussed the disease caused by infection with
the B. dysenteriafe Sonne on the basis of 82 cases studied, I shall
briefly notice the remaining 7 cases.
Bacillus Aertrycke Infections
These cases were as follows*- 5
Bacillus Enteritides (Gaertner) Infections - 1
Bacillus Newport Infections
* 1
ClinicBLlly these cases showed strong resemblances.
The
onset was fairly acute with headache, abdominal pain and vomiting.
Diarrhoea commenced within 48 hours of the onset of the illness and
in the mild cases lasted for 3 days, in the severest for ten days.
In two of the Aertrycke infections there was blood and mucus in the
stools.
Clinically the children initially appeared more toxic than
those suffering from Sonne dysentery.
tenderness present.
In no case was abdominal
Stool cultures were positive in the five
Aertrycke infections, the Gaertner infection being diagnosed sero­
logically on a rising titre.
(From 1 in 2560 to 1 in 81,120 in 7
days) as the stools were negative.
The Newport infection was diag­
nosed upon positive stool culture.
It is obviously wrong tc form
any opinion from such a small number but one deduction may correctly
be drawn and that is that the Salmonella group of infections is
relatively rare as compared with the Sonne group.
Diagnosis from
the Sonne group is based upon the clinical features which show certain
fairly well-marked differences*
The onset is acute but there is a
period of "seediness" of two or three days' duration before the onset
of diarrhoea*
The child is more ill than is usual in Sonne dysentery
and the stools are less frequent although they may occasionally contain
blood and mucus.
The apparent ease of culturing the organism from
the stools is of considerable value in diagnosis.
tions would appear also to be of value.
Serological examina
From my previous remarks it
will be seen that out of 59 healthy children in whom a full Widal
examination was carried out no case agglutinated the Aertrycke organism
while only 5 agglutinated B. enteritides Gaertner to a maximum dilution
of 1 in 80.
Therefore it would appear likely that, as far as
Aertrycke infections go, any agglutinins to a dilution of over 1 in 20
could be regarded as diagnostic.
In the two cases which were investi­
gated in this way the dilutions were 1 in 40 and 1 in 80 respectively.
?he fact that agglutination of B. enteritidis Gaertner to dilutions as
high as 1 in 80 may appear in the serum of normal persons would not
appear to offer any serious difficulty as apparently this organism is
a rapid agglutinin. producer, as witness the enormous dilution of 1 in
81, 120 noted in the single case of this infection.
Diagnosis is therefore possible if a routine similar to that
recommended for Sonne dysentery is followed.
TKEATRtrittt.
This is symptomatic and similar to that outlined
for Sonne dysentery.
- 50
(b) INFECTIVE ENTERITIS OF UNCERTAIN ETIOLOGY.
(1} ACUTE TOXLC ENTERITIS.
(2) ACUTE CHOLERAIC ENTERITIS.
I have already stated that I believed the symptomatic
variety of enteritis to be quite a different condition from the
type to be discussed presently.
To recapitulate briefly I am in agreement with Findlay
and Graham (47, 60,) in that I have never seen an acute toxic type
of enteritis which could be directly associated with an ex-enteral
focus of infection as the cause.
I have seen otitis media
associated with enteritis which cleared up when the middle ear
infection cleared up.
I have also seen otitis media occurring
either as a complication of acute choleraic enteritis or as a
part of a syndrome, namely acute toxic enteritis.
This can
easily and naturally explain the differences of opinion which
exist regarding the treatment of these parenteral foci.
Otitis has engaged most attention and as a result most has been
written about its association with enteritis.
It is obvious that
treatment of otitis which has given rise to enteritis will result
in improvement or lessening of the diarrhoea*
But it will have
no effect in improving the initial condition where otitis is either
a complication or part of the disease.
In fact radical treatment
may have a bad effect upon the seriously ill patient where expectant
treatment would be best.
So far as the division into two distinct types is
concerned, this is done upon clinical and pathological grounds as
will he found in succeeding
^ages,
Graham and M ’Kinnon suggest
that the two types are simply different stages of the same disease
hut in my experience the two entities hreed true.
In ward outbreaks
j
due to the introduction of an infectious case of a specific type the
secondary cases always are of the same specific type.
Another point
in favour of this theory is the tendency for a child in the convales­
cent stage of one variety of enteritis to he re-infected with the
other variety.
This must have occurred in the experience of every­
one who has had any experience of children*s wards.
however, the re-infection is called a relapse.
In most cases,
(8, 115),
imSCTIVITY OP BOTH TYEBS.
It has often been stated that enteritis is infectious hut
the extreme degree of this infectiousness does not seem to have been
fully appreciated until lately.
Rice et al, Front and Greenberg et
j
al have strongly advocated stringent isolation in their papers upon
acute enteritis of the new-born, (8, 43, 50, 60, 61, 104),
From
personal experience of ward outbreaks, I can state that the infectivity of the types of enteritis now under discussion is very high.
This applies particularly to the acute toxic variety and I think
several reasons for this may be advanced.
They will be discussed
later.
Although the dyspeptic, mechanical and symptomatic forms
of enteritis are not infective the differential diagnosis of those
kinds of enteritis from the infective forms is not usually one which
j
- 52
can be carried out under 48 hours;
no diarrhoei® case therefore
should be left in an open ward,
(1) ACUTE TOXIC ENTERITIS.
This is the
No • 32.
most deadlyform of enteritisamong
children
and has a mortality
of 53.1$ in this series.
INCUBATION PERIOD.
Two to four days when baseduponexperience of
ward outbreaks.
ETIOLOGY.
From purely clinical observation it has not been
possible to throw any definite light upon the etiology of this con­
dition but inferences can be drawn which point to investigations
which might profitably be carried out.
INFECTIVITY.
This disease is exceptionally infectious and the
attack rate very high, especially among children under one year.
In 1938, there was an outbreak of this variety of enteritis in a
ward in the Eastern Hospital containing twenty cases of measles,
seven of whom were under one year.
Five of the seven children were
attacked with four deaths, while only one case occurred among the
children of over one year.
MOBS op SPREAD.
While infection may be carried on the person and
the clothes, routes which are easily controlled, it appears that the
most important method of spread is by spray or droplet.
When the
special ward was opened, the greatest care was taken to ensure that
the entire staff was free from any resperatory infections especially
53 -
those of the upper respiratory tract.
Nurses had strict instructions
to report any abnormality of this nature.
No masks were worn, the
remainder of the precautions being directed against infection being
carried on the hands or uniform.
Very soon after opening the ward
a case convalescing from a mild dyspeptic form of enteritis de've loped
the acute toxic type of enteritis and subsequently died, two further
cases occurring shortly after this.
As the prescribed precautions
were being rigorously applied it was decided to try the effect of
masking the nurses who looked after the children and who prepared
the feeds.
occurred.
Since then no further cases of cross infection have
It would appear on the face of it that infection may be
carried in the respiratory tract of apparently normal adults and
from theBe may be conveyed either direct to the children or to their
feeds.
From the general picture the former seems the likelier mode
of spread.
BACTERIOLOGY.
In six of the cases B. protens was isolated from the stools
and in three B. Morgan No.l.
As in my experience both organisms
can be equally well isolated from the stools of children long since
recovered from any form of enteritis and as secondary cases seldom
yield the same organisms, I do not feel disposed to regard them as
being of any significance except perhaps in the case of B. protens
which is a common concomitant of putrefaction.
B. Morgan No. 1.
is fairly often recovered from the stools of children convalescent
j
- 54 from Sonne dysentery*
As already indicated no serological inve sti-
gation of these cases was carried out until the last six months of
1938*
However in twelve cases subsequently investigated serologically
no agglutination of any known pathogen could be found.
In one case
from which B. protens had been isolated the serum failed to agglu­
tinate B. protens.
It seems probable that the disease is caused
either by some unknown bacillus, by a filter passing virus or by a
toxin produced by an unsuspected organism.
The extremely hi$i degree
of infectivity, and the great difficulty in preventing cross-infection
resemble the behaviour of measles, chicken-pox and small-pox very
closely and these are all diseases caused by filter passers.
That
is however a personal opinion based upon undoubtedly very slight
evidence and must necessarily await more definite confirmation.
SEAS OilAL INCIDENCE.
numbers are small but probably sufficient
to show that this type of enteritis tends to occur irregularly
throughout the year (Table 11 )•
autumn and winter.
Peaks are most obvious in thelate
These peaks occur in both winters, the summer
figures are quite irregular and there is little resemblance between
those of 1937 and 1938.
It would be unwise to conclude more than
that the disease occurs irregularly throughout the year with peaks
in the late autumn and winter months.
The clinical impression was
that these cases were relatively infrequent during July, August and
September and became more common in the autumn and winter.
impression is still borne out by events in 1939.
This
At the moment of
writing (August} there is no case of acute toxic enteritis in the
|
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TABLE) 16
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- 83 The intravenous administration of normal saline, dextrose
solution, Hartman’s solution has many devotees, (25, 29, 43, 60, 67,
87, 88, 96, 97, 108, 109, 123, 132, 150, 160) but personally I have
not found this to be any more effective in infants than the
subcutaneous method.
The disturbance of the patient together with the
impracticability of keeping more than two cases going at one time
without having an extremely large nursing staff was an important
factor, militating against the use of this method.
It also has its
dangers because a definite strain is imposed upon the heart in an
already ill child with the consequent risk of cardiac collapse which
must obviously be very great in a toxaemia, and of pulmonary oedema.
Maddock et al hold this view.
In my opinion this method
of giving fluid is definitely contra-indicated in the acute
toxic type of enteritis as these cases are already suffering from
pulmonary congestion and an increase in circulating fluid of the
nature of saline would definitely tend to produce a broncho-pneumonia.
Wilmer’s figures showing Z0% of the deaths as due to broncho­
pneumonia support this view.
I also entirely agree with Kaitland-
Jones and Wilmer that, in the toxic
type, although the dehydrati. on
may be successfully dealt with, the
toxaemia remains unaffected.
I
cannot support the views of Hartman, Hoag and Harpies, Cooper, Cohen
that intravenous fluid is of any more value than subcutaneous fluid.
Transfusion of whole olood has been given some attention but opinion
is uniformily against its use.
In any case the introduction of whole blood into thesecases
unphysiological.
In the dehydrated child the haemoglobin percen­
tage and the red cell count are increased.
This is all an indica­
tion of increased concentration of the blood due to loss of fluid.
These children are not in need of haemoglobin or of erythrocytes
but oi fluid to reduce the concentration and to act as a vehicle
for excretion of accumulated waste products.
I do not consider
that the results obtained by the introduction of normal saline into
the blood stream justify the manipulation of the ill infant involved.
It would seem that plasma might be suitable.
success with plasma.
Aldridge records some
Laurent tells me that he has also used
plasma but that he was not convinced of its value.
I have not
tried this method myself and so I cannot speak as to its efficacy.
Hartman, Ellis and Cooper state that transfusion of whole blood is
of value in the debilitated child recovering from the choleraic
type of enteritis with an associated anaeima.
(3, 25, 29, 43,
45, 67, 68, 100, 91, 104, 172).
As I have already indicated, I prefer the subcutaneous
route.
It is simple and easily managed and the fluid can be given
in one dose or by the drip method.
The fluid which I use is 5J4>
glucose in normal saline and after a trial of both methods of
administration, I have come to the conclusion that the single dose
method at four-hourly intervals gives just as good results as the
continuous drip.
It has the decided advantage that a minimum of
supervision is required.
I would like to stress now the point that
strict asepsis must be observed and for that reason I do not allow
- 85
the nurses to give the subcutaneous saline but do so myself.
The
extremely debilitated infants are very susceptible to infection and
a minute number of organisms introduced subcutaneously can easily
cause sloughing of the overlying skin surface.
I usually give 80-
100 c.c. of 5/c glucose saline into the abdominal wall or either axilla
every four hours.
Contrary to expectation, the discomfort caused
is minimal, due probably to the laxness of the subcutaneous tissues
in the dehydrated infant and on no occasion has the glucose acted as
an irritant.
Occasionally the fluid is not completely absorbed.
Reduction of the four-hourly dose until the glucose saline is com­
pletely absorbed in 2-3 hours-
overcomes this difficulty.
Adminis­
tration of subcutaneous glucose saline may save a child if it is
given in the early stages of the acute toxic type of enteritis;
given
when the child is severely toxic and considerably dehydrated, it may
overcome the dehydration but otherwise it does not affect the usually
fatal course of the disease.
Definite improvement follows the
administration of subcutaneous glucose saline in cases of the
choleraic type of enteritis.
FEEDING.
I have used the method which is so popular among persons
interested in enteritis, namely, a preliminary period of starvation
of from 24-48 hours during which time the infant is given only 5%
glucose in half-normal saline or glucose no sterile water every hour
for a period of ten minutes.
Where vomiting is troublesome, absolute
starvation is imposed, the mouth being moistened with a swab soaked
in glycerine and boracic lotion or simply in water.
In the type
- 86 of case which can he fed by mouth but which is showing signs of
dehydration, subcutaneous fluid is given also and, of course, in the
type with persistent vomiting the subcutaneous method only is adopted,
(25,60, 104, 108, 109, 132, 153, 172).
In some cases, very few, a definite reaction to this
treatment takes place in that the vomiting ceases and the diarrhoea
becomes less in 24-48 hours, but in the majority of cases this is
not the case.
Although Marriott, Marfan and Lelong consider that
the period of starvation should be extended until four or five days
I usually start feeding after 48 hours of starvation as suggested by
Rominger, Czerny, Strausky, Xleinschmidt and Langstein, (38, 87, 88,
96, 97, 99, 123, 124, 150, 160).
When the period of starvation is over, an attempt mu3t be
made to get the infant back on to the food to which he has been
accustomed.
In no case must a breast fed infant be weaned but the
breast feeds should be gradually introduced beginning with feed3
twice daily and slowly building up until the child is back to his
normal feeds again. (43).
Children who have been artificially
fed should be started on feeds of the type to which they are accustom­
ed in a diluted form beginning with two feeds daily and gradually
building up until the child is back on his normal feeding times, then
the strength is gradually increased to normal.
This of course, is
the ideal but in practice the process is not so easy and many attempts
must be made before the child is on his normal diet.
In a large
number of cases the feeding by mouth becomes almost an impossibility
and the child has to be given what he will take.
This often entails
- 87
running through the whole gamut of the artificial foods.
It is
for this transition stage from starvation to normal diet that many
authors are in favour of a milk free diet.
Czerny and Rominger
recommended the use of whey or Moll’s calium lactate whey, Beumer
and Kleinschmidt prefer to start on rice gruel only and French
author’s such as Ribadeau-Dumas and Lelong prefer the use of
vegetable soups or cereal decoctions.
127, 128, 148, 149).
(15, 38, 87, 88, 99, 126,
Dried buttermilk preparations have been
successfully used by Langstein, Engel and Feer.
Marriott, Utheiin,
Schiffe and Mosse, Bischoff, Beumer and others recommended the use
of lactic acid milk mixtures instead of buttermilk soup while
Weissenberg, Behrens, Gouce and Templeton have used citric acid
milk.
Personally, I have found bengerised milk to be the most
useful feed in difficult cases.
The question of banks of mother’s milk requires investiga­
tion but many administrative difficulties have to be overcome before
it becomes practicable.
(12, 14, 16, 44, 56, 65, 96, 97, 124, 158,
164, 168, 169, 170).
FRUIT piETS.
Some ten years ago Moro and Heisler introduced the
apple diet in the treatment of diarrhoea.
Feer also reported on
treatment of diarrhoea with fruit juices and bananas.
Since then
a great deal of investigation has been done on this subject.
(56, 74, 130,)*
88 -
Heisler and Kohlbrugge consider that the acids, which inhibit
bacterial growth are specific while Malyoth
believed that the
pectins, which have a high adsorbing power, act like charcoal.
Favourable results have been published by many authors (10, 37, 43,
j
57, 64, 75, 18, 58, 74, 89, 98, 55, 106, 107, 121, 122, 129, 130,
135, 137. 126, 127, 128, 153, 163, 171,)
)
Like Smellie, however, I was quite unable to convince myself that
apples or bananas were of any real value in the treatment of acute
enteritis of either type.
SUPRA-RENAL CORTEX.
.Harrop (66) considers that administration
of supra-renal coptical hormone may be of value in cases of dehydration.
I have tried this form of treatment in a few cases but I have I
not been impressed by the results.
Laurent (91), who has used supra-;
renal cortical extract fairly extensively states that he has now
given it up as he does not consider it to be of value in treatment.
DRUGS.
|
In the earliest stages castor oil may be beneficial but in
the later stages with a debilitated child it is contra-indicated.
Opium and Belladonna may be used with some benefit where colic appears
to be causing pain.
Although Gzerny and Keller (38
) consider
alcohol to be contra-indicated I have found brandy to be of value
because it is a food and a sedative and to my mind is the safest and
most serviceable medicine to use.
As far as chemotherapy goes, I can only state that in my
experience it is of no value as a prophylactic and that the few
j
- 89
cases which have been treated in this way have not been improved.
VITAMI U S .
When the child is established on its normal diet,
vitamins ought to be introduced into the diet.
Orange juice and
cod-liver-oil or one of the concentrated vitamin products are
added to the diet.
Too early administration of orange juice
s
h
l
a
o
w
l
y
s
been found to upset some of the infants.
PROPHYLAXIS.
feeding.
The most important factor in prophylaxis is breast
This fact has been recognised for many years but in spite
of this the incidence of breast feeding is falling.
Spence
estimates that at the present time, in most of our big towns, 20$30$ of our babies are artifically fed from birth and that not more
than a third pf the mothers of these towns are fully feeding their
babies up to the sixth month.
It is quite possible, to ray mind,
that an immunity is conveyed to the infant in the mother*s milk.
In any case there cannot be the slightest doubt that the breast fed
infant is relatively immune from enteritis.
Spence is quite con­
vinced that breast fed infants show a greater freedom from disease
than artifically fed infants and Smellie (JL53) strongly supports this
belief,
My own figures are quite definite, as only three of the
children of nine months and under with acute enteritis of unknown
etiology were entirely breast fed up to the onset of the illness.
If artifical food must be given, properly clean preparation of the
feeds by an individual who is at least masked and whose hands have
been carefully cleaned will do much to prevent infection of the feeds.
- 90 -
In the early stages much can he accomplished by withdrawal of milk
feeds and the giving of 5$ glucose in £ normalsaline for 24 hours
by mouth.
It has been my experience in wards in which there has
been an outbreak of enteritis that prompt treatment in this way of
an infant who has passed a relaxed stool will often abort the attack.
(153, 173).
C H A P T E R
III.
UNO LASS IF IABIE TYPES OF ENTERITIS.
These cases were namely very mild attacks of diarrhoea and
numbered 42 in all.
9 (21.4$) were under one year and 25 children
(59.5$) were between one and three years of age.
The remainder
were evenly distributed between the ages of 4 and 14 years.
It
will be noticed that only one fifth of the cases were below one
year of age.
No deaths occurred among this group of cases.
On going over the case papersafter two years, I noticed that
the majority of the cases which could
the first year of the investigation.
not be classified occurred in
i
|
On fresh consideration and in
the light of increased experience I tried
to re-assess these cases.
|
Ten (23.8$) on clinical grounds could have been included in the
i
bacterial group and one among the symptomatic group.
It should be
noted that all of the ten cases just mentioned occurred before
serological examination was undertaken.
The bacteriological
findings from stool examinations were as follows*-
!
t
91
B* Morgan I, in 5 cases*
B* protens , in 2 oases*
j
In the remaining 35 cases no abnormal organisms were
found in the stool.
C H A P T E R
IV.
ROUTINE INVESTIGATION OF CASES OF ENTERITIS*
This is a suitable point at which to recapitulate briefly
the salient points in investigation of all cases of enteritis in
children.
A complete history must be talcen with special reference
to feeding including recent changes of diet, recent illnesses and
contact with other children suffering from enteritis*
Clinical
investigation must be thorough and should include examination of the
tympanitic membranes at frequent intervals and microscopic examination of the urine.
The stools should be examined bacteriologically
on two successive occasions before accepting a negative result*
Serologicalexamination should
the fourteenth
be carried out in every case after
day of illness.
The mechanical types can quickly be segregated and helped by
good history, taking the dietetic and symptomatic forms recognised,
but difficulties arise in assessing cases falling into the other
groups.
In a large number of cases the infective type of known
etiology can be separated from the infective type of uncertain
etiology if it is remembered that the former is commonest in
children in over one year, that it is excepting typhoid and para-
j
j
!
- 92 -
typhoid infections, a relatively mild disease and that the stools
of the dysenteric cases, especially Sonne dysentery, often contain
blood and mucus.
short.
The course of the dysenteric illness is usually
In contrast the type of uncertain etiology is oftenest
found in infants of under one year, the illness is severe and becomes
progressively more severe the younger the victim and the stools never
contain blood and/or mucus.
In the typical cases, then, the separa-
tion of the two types on clinical grounds is moderately simple.
However, when atypical and mild cases are encountered it becomes
I
11
extremely difficult to separate the types into the main groups.
|,
Whe n this is the case it becomes necessary to diagnose in retrospect,
relying upon the course of the illness and the results of bacteriolog­
ical examination of the faeces and on serological examination.
As
regards the acute toxic and choleraic forms of enteritis of uncertain i:
etiology certain points should be kept in mind.
In the former
toxaemia is prominent, with frequent vomiting and only slight dehydration.
Gough is present in the earliest stages and is a point of
i
i
j
i
some significance in the diagnosis.
temination.
Death is a too frequent
In the latter type diarrhoea and dehydration are
prominent and vomiting and cough are not troublesome.
symptomatic trestment is fairly good in the
Response to
acute choleraic form but
rarely occurs in the acute toxic form.
Usually it requires a period of 48-72 hours before one can
place a fair number of the cases and often even a longer period is
required as some of the dysentery group must await the result of
- 93 -
serological examination*
The speed of arrival at a correct
diagnosis is not of great moment from the patients1 point of view
with the present rough and ready methods of treatment*
But from
the point of view of other children, this delay is of considerable
importance, and forms one of the major problems of the administration I
of an hospital dealing mainly with young children.
enteritis must be nursed in separate cells.
All cases with
j
The fact that it is so
often impossible to arrive at a diagnosis on first examination mates
J
it imperative that these children should not be nursed in open wards,
j
even with "barrier" nursing” on account of the grave risk of crossinfection.
C H A P T E R
j
V.
THE EASTERN HOSPITAL ENTERITIS UNIT. ‘
This thesis would not be complete without a description of
the enteritis unit which housed the majority of the cases discussed
in these pages.
This unit consists of nineteen cells (with complete
structural separation) banked on either side of a central corridor
but without ventilation into the corridors.
a side ward accommodating two patients.
There is, in addition,
A duty room with bowl and
instrument sterilisers is provided together with one bath-room and
one sluice room containing an automatic single bed-pan steriliser.
Ordinary dietary is served from a kitchen which also acts as a
receiving room and sterilisation room for used feeding bottles.
>
After sterilisation the bottles are passed through a hatchway into
an adjoining milk room which is reserved solely for the preparation
of infants1 feeds under an aseptic technique.
Prior to admission
of the first case to the enteritis unit, certain limitations were
agreed upon as to its use.
In the first place the upper age limit
of children treated was placed at five years.
This was done,
primarily, to avoid difficulty with lavatory accommodation but, as
can be seen from my figures, the demand for admission in the older
age groups is very limited and these cases when they do occur are
mild, if enteric fever cases are excluded.
In order to facilitate
j
nursing an attempt was made, also to limit the accommodation provided
for bottle babies to one third of the total accommodation - the
reserved cells being placed in the immediate vicinity of the duty
room.
In practice it was very
soon found impossible to adhere
to
this - the demand for admission
in the age group under one year
beingj
so great as to require on occasion considerably more than half the
accommodation.
A general aseptic nursing technique is employed
[
'
similar to that used in the barrier and other isolation wards of the
hospital.
This involves the wearing of a
patients.
As has already been
mask in attending to
the j
mentioned, at first there were one
or two cases of cross infection but since the introduction of masks
this has entirely ceased.
A large staff is employed (in the ratio
of two nurses to three patients,) and a sharp separation of nursing
duties is made intos-
I
j
- 95 -
A. The preparation of feeds.
B. The giving of feeds,
j
f1
and
■j
C. Washing and changing of infants.
|
Ho interchange of duties is permitted hut, after a period
of fourteen days, duties are changed round to allow junior staff
j
particularly to obtain experience in all aspects of the work.
PREPARATION OF FEEDS.
Feeds are prepared in the milk room by a
i
senior member of the nursing staff - normally the ward sister or her
deputy.
During the preparation of feeds the nurse is gowned, gloved
and masked and remains in the milk room until all the feeds have been
prepared for the ensuing 24 hours.
The requisite number of feeds
for individual patients is then sterilised in a Soxhlet apparatus,
cooled and stored in the refrigerator in a wire-crate - individual
crates being marked with a metal label to indicate the cell number
of the particular patient.
I
Single feeds are withdrawn as required,
warmed and given by one of the staff specially allocated to feeding
j
duty.
i
Particular attention has been paid to the administration of
feeds and, with the staff available it is possible to ensure that
babies, are taken out of bed and fed in a proper nursing position
without hurry or fuss.
This is desirable in any case but particu­
larly in the severe forms of gastro-enteritis when prolonged nursing
in the recumbent position is likely to aggravate any respiratory
infection by encouraging hypostatic congestion of the lungs.
t
-
96
-
During the time of the investigation, it was occasionally
necessary to re-admit enteritis cases because diarrhoea had recurred
shortly after discharge from hospital.
This was found on investiga­
tion to be due invariably to unsuitable feeding.
In order to avoid
this possibility a simple form was evolved which is given to the
parents on discharge of the child and which describes precisely the
character, quantity and frequency of feeds which have been found
suitable as well as the details of other items deemed necessary such
as cod-liver-oil and orange juice.
It will be noted that the hospitalisation technique is
similar to that quoted by Maitland-Jones from the reports of Gladys
Dick and to that recommended by Felsen (46,104,)
1 -
ENTERITIS
OF
CHILDHOOD,
SUMMARY AND CONCLUSIONS.
SUMMARY.
The main object of the thesis is to clear up the
uncertainty of classification of the various forms of enteritis of
childhood which, of course, is a reflection of the great difficulty
in diagnosis.
However, while the subjects of classification and
diagnosis were being investigated many efotheft,points of interest
emerged which were followed up to a certain extent and some
conclusions drawn.
A short historical review from the time of Hippocrates to
the nineteenth century is given.
This is designed to show how
certain basic facts such as the relationship between diarrhoea and
teething, hot weather, artificial feeding and overcrowding came to
be recognised.
There then follows a discussion of the various
classifications based upon clinical, pathological, bacteriological
and biochemical findings and which have not proved to be very
satisfactory.
General etiological factors of enteritis of childhood then
come under discussion with special emphasis upon the value of
progressive public health legislation in causing a reduction in
the death rate from enteritis as a whole.
The suggestion is ther^nade that one of the reasons for the
difficulty in classification lies in the fact that the clinical
basis which forms the foundation of every investigation is at fault
This, it is suggested, might he due to the true state of affairs
being lost in a maze of biochemistry and bacteriology*
The classification adopted in the investigation of the
275 cases of enteritis is as follows!•»
A.
NON-INPECTIVE ENTERITIS.
(a)
DYSPEPTIC ENTERITIS
(b)
MECHANICAL ENTERITIS
(c) SYMPTOMATIC ENTERITIS*
B.
C.
INFECTIVE ENTERITIS.
(a)
ENTERITIS OP KNOWN ETIOLOGY
(b)
ENTERITIS OP UNCERTAIN ETIOLOGY
(1)
ACUTE TONIC ENTERITIS
(2)
ACUTE CHOLERAIC ENTERITIS.
UNCLASSIPIABLE TYPES OP ENTERITIS.
The above classification was adopted at the commencement
of the investigation and was based upon previous experience*
It
was not found necessary to alter this classification, but a few
of the cases originally included in the unclassifiable group were
subsequently thought to be more suitably included in other groups.
-3
CHAPTER If deals with the non-infective forms of enteritis and
shows that this group is not of great importance*
form of enteritis is shown to he easily treated*
The dyspeptic
The mechanical
form may include certain serious conditions such as hypertrophic
pyloric stenosis and intussusception hut is rare*
The syintoinatic
form is discussed at length and it is suggested that swallowed
sputum and excretion of toxin through the intestinal wall might well
he the two most likely causes*
The association of enteritis with
otitis media is noted and discussed fully*
The conclusion is
reached that undue importance has been attached to the symptomatic
form of enteritis.
An analysis of 492 cases of measles is used
to support this view.
CHAPTER II discusses the subject of infective enteritis of known
etiology hut is confused mainly toSonne dysentery.
Seasonal
incidence, incubation period, mode of spread, clinical features and
complications are touched upon and finally the subject of diagnosis*
Here I try to show that the only reliable method of diagnosis is by
serum agglutination and figures are produced in support of this.
This leads up to a discussion on the best routine method of dealing
with a ward outbreak of some dysentery and the finding of mild cases
and carriers.
Treatment and pathology are also mentioned*
Infective enteritis of uncertain etiology is then discussed
and the division into two typessand
(l) Acute Toxic Enteritis
(2) Acute Choleraic Enteritis
upon clinical and pathological grounds justified.
Both types are
4
fully discussed and theories advanced as to their etiology*
It is suggested that the acute toxic type is a virus infection
and that the choleraic form is of bacterial origin.
Seasonal incidence, clinical picture, complications, pathology,1
diagnosis and treatment are dealt with fully*
The question of the
i
•i
value of the various forms of treatment is gone into and personal
!
experience of certain of these noted.
CHAPTER III includes the unclassifiable forms of enteritis.
These are probably mild forms of the dysentery group and of the
dyspeptic group.
CHAPTER IV deals with the routine investigation of cases of
enteritis and makes certain suggestions which are in the main
j
that serological examination must be carried out, clinical examination must include examination of ears and urine together with a
most thorough investigation of the respiratory tract*
CHAPTER V describes briefly the enteritis unit at the Eastern
Hospital in which the work recorded was carried out*
j
comclusiohs.
i
I
;
A*
The suggested classification is satisfactory.
B*
Eon-infectious enteritis is relatively
unimportant and this includes true symptomatic
enteritis.
j
i
-5
C.
The diagnosis of the dysenteries, especially
of Sonne dysentery, can he rendered much more
accurate if serum agglutination reactions are
tested.
D.
Infective enteritis of uncertain
etiology is
of two types one probably due to
a virus and
the other to a bacillus.
S«
Treatment of all forms of enteritis is largely
empirical and is not satisfactory in the case
of enteritis of uncertain etiology.
It is
suggested that adult serum might contain
antibodies.
All cases of enteritis must be isolated and
a true •barrier* technique adopted by nursing
and medical staff.
-1B I B L I O G E A P H T .
/
Abramson and Frant (1938).
Adams. (1937).
Aldridge (1938).
Amer. Journ. Dis. Childh. ,55, 1288.
Proc. Roy. Soc. Med. 30, 1308.
Arch. Dis. Childh.
13, 287.
Andrewes and Inman (1919) Monograph. Med. Res. Com.
Arnold (1927) Arch. Pediatr. 44, 71.
Adam. (1927) Jahrb. Kinderheilk 8, 116.
Aron
(1924) Verh. d. Gesellsch. F. Kinderheilk, Innsbruck.
Blacklock and Graham. (1936) Trans, Roy. Med. Chir. Soc. Glas. 1.
Bratton. (1939) Personal Communication.
Brubaker (1937) Journ. Mich.Med. Soc. 36, 40.
Butler, McKhann and Gamble (1933) Journ. Pediatr. 3, 84.
Behreus. (1929) Arch. F. Kinderheilk, 86.
Beumer. (1937) Uber die Ernahrung des Sauglings.
Beumer
(1930) Deutsh. Med. Wochenschr.
Beumer
(1935) Med. Klinik. 32.
Bischoff (1931) Monatschr. F. Kinderheilk, 61, 174.
Blackfan and Maxey (1918). Amer. Jour. Dis. Childh. 15, 19.
-2Borovsky. (1936)
Araer. J. Dis. Childh. 1487 , 51.
Besseau (1935). Mschr^ Kinderheilk, 63, 4.
Besseau and Bossert (1919) Jahrb. Kinderheilk, 89, 213.
Besseau, Rosenbaum, Leichentritt; (1922) Mschr.Kinderheilk, 22,
643.
Boyd. (1923) Arch. Intern. Med. 31, 297.
Chaudhuri (1937) Indian. Journ. Pediatr. 4, 11.
Christie (1939)
Personal Communication.
Cohen, Miller and Kramer (1933) Journ. Pediatr, 3., 299.
Coller (1936)
Surg. Gyn. Obstr. 6j3, 249.
Coller, Dick and Maddock (1936). Journ. Amer.Med.Assoc. 107,
1522.
Coller, P.A., Bartlett, Bingham, Maddock and Pederson. (1938)
Ann.Surg. 108, 769.
Cooper (1937) Arch. Dis. Childh. 12, 339.
Catel
(1935).
Klin. Wschr. 8, 127.
Catel
(1937)
Catel
and Graevenitz (1925).
Jahrb.
Kinderheilk. 109,249.
Catel
and Graevenitz (1926).
Jahrb.
Kinderheilk, 112, 227.
Mschr. Kinderheilk. 69, 393.
Catel and Pallaske (1933) Jahrb. Kinderheilk, 139, 165.
Csape and Kerpel-Pronius (1934) Mschr. P. Kinderheilk, 60,154.
-3Csape and Wollek (1935). Ztschr. 5*. Kinderheilk, 57, 554.
Currado (1932). Clin. Pediatr. 14, 232.
Czerney-Keller (1928) Des Kindes Ernahrung. Vol. 11.
D I
(1936) Indian. Journ. Pediatr. 3, 165.
Peak. (1933). Ztsehr. Kinderheilk, 55, 196.
Denzer and Anderson (1921). Amer.Journ.Dis.Childh. 21,565.
Ebbs (1937) Proc. Hoy.Soc.Med. 30,1297.
Ellis
(1933) Practitioner, 131, 642.
Engel
(1930) Deutsch. Med. Wschr. Ko.ll.
Falconer and Lyall (1937) Brit.Med.Journ. 2, 1116..
Felsen (1936) Arch. Pediatr. j6, 133.
Findlay (1932) Arch. Dis. Childh. 7, 307.
Floyd
(1925) Arch. Otolar. Chicago. 1, 411.
Frant
and Abramson (1937). Journ. Pediatr.11,772.
Frant and Abramson (1938) Amer.Journ.Pub.Health.28,36.
Frazer, Kinloch and Smith (1926). Journ. Hyd. 25, 453.
Fullerton, Lyall and Davidson (1932) Lancet, 1, 558.
Fyfe (1927) Journ. Hyg. 26, 271.
-4Pinkelstein (1931) Jahreskurse. P. Arztl. Portb.
Panconi (1930). Deutsch. Med. Wschr. .56, 1949.
Peer (1937) Volume Jubilaire en l ’honneur de L.E.C. Dapples.
Pilke (1932) Pediatr. E. Puericult. 2, 13.
Prenklowa (1932) Pedjatr. Polska
Goodhart.
Graham
12, 360.
Diseases of Children.
(1938)
Practitioner. 141. 733.
Greenberg and Wronker (1938). Journ. Amer.Med.Assoc.110.563.
Goldman (1937). Jahrb, Kinderheilk, 149, 365.
Goldschmidt (1931) Jahrb. Kinderheilk, 135, 346.
Giblin and Lischner (1935) Arch. Pediatr. 52.355.
Gouce and Templeton (1930) Amer.Journ.Dis.Childh. 39, 265.
Harrop (1936) Bull. John’s Hopk. Hosp. 59,11.
Hartman (1928) Amer.Journ.Dis.Childh. 35, 557.
Hoag and Karples (1931) Amer.Journ.Dis.Childh. 42, 291.
Hood (1938) Journ. Ark.Med.Soc. 3j4, 238.
Hassmann (1936) Wien.Klin.Wschr.Ho.26.
Hassmann and Deak (1933) Ztschr. Kinderheilk, 55, 248.
-572)
Hassmann and Herzmann (1934) Ztschr. Kinderheilk, 56, 512.
73)
Hassmann and Scharfetter (1934) Ztschr.Kinderheilk, 56, 609.
74)
Heisler (1928) Dennoch Landarzt. Muchen.
75)
Herzmann (1938) Kinderarztl. Praxix, £, 1.
76)
Jacoby (1938) Guys Hosp. Rep. 88, 367.
77)
Jeans and Ployd (1926) Journ.Amer.Med.Assoc.87,220.
78)
Johnson, Ebbs and Kaake (1933) Canad.Pub.Health Journ.24,443.
79)
Johnson and Kaake (1935) Journ. Canad.Med.Assoc.53t 632.
80)
Johnson, Brown, Tisdall and Prazer (1933) Amer.Jour.i)is.Childh.
41, 1.
81)
Keller (1934) Indian Journ.Pediat.1, 115.
82)
Kerrin (1928) Journ. Hyg. 28, 4.
83)
Keller (1934) Med.Klin. 38.
84)
Keller (1937) Klin.Wschr. 14* Ko.27.
85)
Keller (1932) Ztschr. Kinderheilk,53, 253.
86)
Keller and Gyorgy (1932) Ztschr. Kinderheilk, 53, 279.
87)
Xleinschmidt (1935) Klin. Wschr. 1, 257.
8
8
)
89)
Kleinschmidt (l938)Eeerfs Lehrbuch der Kinderheilkunde.
Kohlbrugge (1930) Klin. Wschr. 9, 408.
-6Langer (1937) So.Afr. Med.Soc. 2, 57.
Laurent (1939)
Le Mee (1937)
Personal Communication.
Proc.Roy.Soc.Med. 30, 1293.
Levine, Wheatley, McEachern, Gordon and Marples (1938).
Amer.Jour. Dis.Childh. 56, 83.
Lesne, Launey, Loisel.
Lust (1913)
(1935) Bull. Soc. Pediatr.Paris.33, 712.
Jahrb. Kindersheilk 21* 383.
Langstein. Dystrephien und Durchfallskrankeiten im
Sauglingsalter.
Langstein.
(1927) Deutsch. Med.Wschr. Ho.23.
Leffkowitz. (1932) Ther. D. Gegenw. 73,44.
Lelong. (1938) Le traitement et la Prophylaxie du Cholera
infantile•
Maddock and Coller (1937) Journ. Amer.Med.Assoc.108, 1.
Maizels and McArthur (1929) Q.uart.Journ.Med.22. 581.
Maizels amd McArthur (1930) Quart•JourniMed.23,171.
Maizels and Smith (1934) 1, 1329.
Maitland-Jones (1939) Bulletin Mensuel de 1 TOffice
International d ’Hygiene Publique. 31, 473.
Manifold (1928) R.A.M.C. Journ. 6.
Manville, Bradway and McMinis (1936) U.W.Med.Seattle, 35,441.
Manvilie (1938) Arch.Pediat. 5J5, 76.
-7(108)
Harriott, Hartman and Senn (1933). Journ. Pediatr. 3, 181.
(109) Mayo. (1934) Med.Journ.Austral. 1, 535.
(110) McMahon (1928) Arch. Otolar, Chicago. 7., 13.
(111) McCance (1936) Lancet 1, 704.
(112) McKinlay (1937) Amer.Journ.Drs.Childh. 5£, 1252.
(113) McKonkey and Couper (1938) Arch.Dis.Childh. 13, 137.
(114) McCance (1938) Proc.Roy.Soc.Med. 31, 723.
(115) McKinnon (1933) Canad.Pub.Health.Journ. 24, 53.
(116) Menton (1929) Erit.Med.Journ. 1, 1115.
(117) Mita
(1921) Journ.Infect.Dis. _29, 580.
(118) Mitchell, McCarthy, Leichliter and Seinsheimer (1929) Journ.
Amer.Med.Assoc. 92,970.
(119) Moncrieff (1933) Practitioner. 150, 307.
(120) Meyer (1909) Jahrb. Kinderheilk. 71.
(121) Malyoth (1934) Klin.Wschr. 13, 51.
(122)Kalyoth (1931) Klin. Wschr. 10. 1159.
(123)Marfan
(1930) Les affections des voies digestives dans la
premiere enfance.
(124) Marriott (1935) Infant Nutrition.
(125) Mitchell (1922) Arch.Pediatr. 39,291.
-8126)
Moll. (1922) Leitfaden fur die Zubereitung der diatetischen
Sauglingnahrugen. Wieri.
127)
Moll.
(1923) Mschr. P. Kinderheilk.
128)
Moll.
(1923) Mschr. P. Kinderheilk 26, 250.
129)
Moro
(1908) Munch. med.Wschr. 1637.
130)
Moro.
(1929) Klin. Wschr. 8, 24.
131)
Orr
132)
Pearson (1938) Clin. Journ. 6.7, 280.
133)
Parsons (1924)
134)
Park
135)
Popoviciu (1931)
136)
Paffrath (1930) Mschr. Kinderheilk. .47, 525.
137)
Platenenga (1925)
138)
Rice, Best, Prant and Abramson (1937) Journ.Amer.Med.Assoc.
109. 475.
139)
Ritchie (1916) Lancet. 1, 1257.
140)
Rowntree (1922) Physiol. Rev. .2, 116.
141)
Ruhrah.
142)
Ratner and Gruehl
(1936)
(1925)
26.
253.
Surg.Gyn.Obstetr. 63, 527.
Lancet. 1, 687.
Rev.Prans.Pediatr. Ko.l.
Rev.Prans. Pediatr. 7., 473.
Jahrb. Kinderheilk. 109. 195.
Pediatrics of the Past.
(1934) J. Clin. Invest. 13, 517.
-9Reuss.
(1934)
Scritti.Med. in onore di R.Jemma.
Reuss.
(1936)
Wien. Klin. Wschr. Ho. 25.
Rosenbaum (1928) Zschr. Kinderheilk 40.
Rosenbaum (1928) Zschr. Kinderheilk
39, 121.
/
Renz
(1922) Munch. Med. Wschr. 6.9, 1338.
Ribadeau-Dumas.
Traite de Pathologie Medicale Pediatric V o U l l
Ribadeau-Dumas (1930) Soc.Med. du Hop. de Paris.
Rominger.
Schiff
The Diseases of Children. Vol. IV.
(1938) Journ. Amer.Med.Assoc.111. 2458.
Sears, Schwichtenberg and Schwichtenberg. (1938) Journ.Immun.
a s i # 83 .
Smellie (1938) Lancet, 1, 969.
Smith
Diseases in Children.
Smith and Pried (1937) Journ. Pediatr. 10, 495.
Still
History of Pediatries.
Scheer and Abraham (1930) Jahrb. Kinderheilk. 130. 45.
Schiff and Moses (1924) Jahrb. D. Kinderheilk. Beinheft 3.
Smith, Wharton and Kerper (1923) Arch. Pediatr. 40, 588.
Strausky.
Leitfaden der Kinderheilkunde der rtArs Medici*1.
-10(161) Tezner and Ebel. (1926) Mschr.
F
.
Kinderheilk, 33, 294.
(162) Tallerraan (1934) Arch. Dis. Childh. £, 189.
(163) Urbanitsky (1933) Munch.
Med.Wschr. 80, 1219.
(164) Utheim
Me tab. Res. 1, 803.
(1922) Journ. of
^
'■
(165) Weise (1926)
Mschr. Kinderheilk. 31, 404.
(166) West
Diseases of infancy and childhood.
N.'.
.
(167) Weinberg (1921) Ztschr. F.Kinderheilk. 29, 15.
(168) Weissenberg (1926) Arch.
F.Kinderheilk, 78.
(169) Weissenberg (1930) Arch.
F.Kinderheilk, 90.
(170) Weissenberg (1932) Arch.
F.Kinderheilk. 97.
(171) Wiskott. (1931) Klin. Wschr. 10, 1252.
(172) Wilmers (1938) Proc.Roy.Soc.Med. 31, 755.
Additional References.
(173) Spence
(1938)
Brit. Med. Journ. 2 , 729.
(174) Registrar Generals Statistical Review (1910 - 1937).
(175) Annual Report of Chief Medical Officer of Ministry of Health
(1936).
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