Acute diarrhœa in children

Acute diarrhoea in children Dr P.N. PAI, Bombay

Diarrhoea may be defined as a sudden and abnormal increase in the frequency and change in the consistency of stools. Acute diarrhoea is usually associated with dehydration and electrolytic disturbances which are often severe in children. In India diarrhoea is the second leading cause of death in children and it accounts for about 20% of hospital admissions and 7% of deaths. 1 Homoeopathy has a good deal to offer in the treatment of diarrhoea even in the moribund stages as described by Borland, 2 but probably its efficacy has not been demonstrated well so far. I t is necessary to pick out a few remedies and their infallible indications since almost all the severe cases in the advanced stages present very similar pictures and few children are in a condition to narrate the symptoms. No time can be lost in studying and selecting remedies. With a desire to verify the efficacy of our remedies, simplify the treatment of such cases and if possible, add a useful chapter to our existing literature, a study of 500 cases of acute diarrhoea in children was undertaken in collaboration with m y friend, Dr V. B. Athavale, ~LD., D.C.H., a senior and reputed pmdiatrician of Bombay. ~ E T H O D S AND MATERIAL

Severe cases of infantile diarrhoea are seldom treated in private practice and all such cases are admitted in allopathic hospitals even by the best prescribers. Most of these cases have a sudden onset and a severe and rapid course, and it i s not possible to say that early treatment can stop the progress, because this has not happened in the best hands in a number of cases. Correction of fluid and electrolyte balance in most of these cases is as important as medicinal treatment and Dr Athavale's advice was always sought in this respect. I t is worth mentioning here that a 3-year-old child with severe diarrhoea and dehydration recovered completely with intravenous fluid therapy only and no medicines were given. This may be a chance cure but it underlines the value of the therapy. All severe cases of diarrhoea were admitted in private nursing homes for the purpose of efficient management and homceopathic treatment was carried out in all the cases. This study covers a period of 5 years from 1958 to 1962. All the interesting findings and the method of treatment are discussed in this paper. CAUSES

OF D I A R R H ( E A

Causes of diarrhoea are said to be infective, dietetic and practically all the cases of acute diarrhoea with dehydration disturbances are infective in origin. The causes of diarrhoea history are in fact predisposing factors. These are Hsted in the

parenteral, but and electrolyte as given in the following table:

THE BRITISH HOM(EOFATHIC JOURNAL

32

TABLE 1 Causes of Diarrhoea 1 2 3 4 5

Teething . . . . . . . . Starting bottle feeds Starting solid food and food'allerg; Eating earth, coal and mud .. Colds and cough . . . . . . 6 Measles . . . . . . . . 7 Worms .... 8 Change of residence'" .. .. Total

. . . . . . . . . .

No. of cases

Percentage

177 120 53 31 52 13 36 18

35.4 24.0 10.6 6-2 10.4 2.6 7.2 3.6

500

100.0

D e n t i t i o n a n d s t a r t i n g of b o t t l e feeds were the causes of diarrhoea i n 297, i.e. 5 9 . 4 % of the cases as is seen from Table 1. I n spite of these various predisposing factors, the p r e s e n t i n g pictures were similar a n d the s y m p t o m s i n all cases were covered b y one of three remedies as will be discussed later. A n appreciable n u m b e r of children were suffering from r e c u r r e n t diarrhoea a n d the cause of the a t t a c k i n n o n e of those cases helped i n the selection of the remedies. Thus, a n inference can be d r a w n t h a t the causative factor may not guide one to the selection of a r e m e d y i n the desperate stages of acute diarrhoea a n d t h e acute exacerbations of chronic diarrhoea. I t is surprising to n o t e t h a t o u t of the 177 cases of d e n t i t i o n diarrhoea i n the a d v a n c e d stages, n o t a single case h a d the s y m p t o m s of Cfmmomilla, Podophyllum, Calc. ~hos. or Silicea. I t is w o r t h m e n t i o n i n g here t h a t the period of p r i m a r y d e n t i t i o n e x t e n d s from the age of 6 m o n t h s to 2 years a n d i t is n o t correct to describe a n y diarrhcea occurring d u r i n g this period as d e n t i t i o n diarrhoea. D e n t i t i o n itself generally gives rise to mild or moderate diarrhoea n o t associated with d e h y d r a t i o n . Therefore, i n the above cases, d e n t i t i o n has n o role as a causative factor. Hence, remedies like Chain., Calc. phos., etc., r e c o m m e n d e d for d e n t i t i o n diarrhoea are likely to fail i n these cases as confirmed b y our experience i n the above cases. These remedies, however, act v e r y well i n m i l d to moderate cases n o t associated w i t h dehydration. FREQUENCY

OF

RECURRENCE

The following table gives f r e q u e n c y of attacks: TABL~ 2 Frequency of Attacks a b c d e f g

NIL Once in Once in Once in Once in Once in Once in

15 days 1 month 2 months 3 months 4 months 5-12 months Total

. . . . . . . .

~

.

..

No. of Cases

Percentage

52 2O 35 3O 50 118 195

10-4 4.0 7.0 6.0 10-0 23.6 39.0

500

100.0

I t is seen t h a t only 1 0 . 4 % of the children did n o t give h i s t o r y of r e c u r r e n t diarrhoea a n d t h a t 17% (b, c a n d d) were a c t u a l l y suffering from chronic

33

ACUTE DIARRH(EA IN CHILDREN

diarrhoea t e m p o r a r i l y checked or suppressed by t r e a t m e n t d u r i n g the periodical exacerbations. These children suffered from severe m a l n u t r i t i o n , m u l t i p l e v i t a m i n deficiencies a n d anaemia resulting in delayed milestones a n d s t u n t e d growth. Children who h a d the a t t a c k s at i n t e r v a l s of 2-4 m o n t h s c o n s t i t u t e d 3 3 . 6 % a n d t h e y suffered less in this respect where as in the r e m a i n i n g group (g) with one or two a t t a c k s i n a year, growth a n d d e v e l o p m e n t were n o t affected b y diarrhoea as such. TABLE

3

Monthly Distribution and Mortality Month

Recovered

%

August .. September .. October .. November December ii

18 20 22 24 36 45 61 56 49 55 51 31

94.7 95.2 95-6 92.3 94.7 93.7 91.1 91-8 92.5 94.8 96-5 94" 0

Total

468

January February March April . . May . . June . . July . .

.. .. .. . . . .

. . . .

..

i

.I

Diod

9

%

Total

Percentage of Total

5-3 4.8 4.4 7.7 5.3 6-3 8.9 8.2 7.5 5.2 3.5 6.0

19 21 23 26 38 67 6I 53 58 53 33

3.8 4.2 4.6 5.2 7.6 9-6 13-4 I2.2 10.6 I1.6 10-6 6-6

500

1O0-0

32

48

I t is seen from the above table t h a t diarrhoea is endemic in B o m b a y b u t there is a n appreciable rise in the incidence d u r i n g the period from J u n e to November, especially in the m o n t h s of J u l y a n d August when the relative h u m i d i t y is high. There is, however, n o striking v a r i a t i o n i n the m o r t a l i t y in different mouths. This seasonal v a r i a t i o n is v e r y useful in selecting a group of c o n s t i t u t i o n a l remedies for p r e v e n t i o n a n d t r e a t m e n t of r e c u r r e n t diarrhoea. However, i n t h e a d v a n c e d stages of acute diarrhoea this factor was n o t f o u n d to be usefu] in selecting the remedies. Definite a n d r e l e v a n t family h i s t o r y could be o b t a i n e d o n l y in 110 cases as detailed i n the table below: TABLE 4 N o . of cases A l l e r g y to m i l k A l l e r g y to fats A l l e r g y to pulses

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recurrent diarrhoea in other family members .. Tuberculosis . . . . . . . . . . Total

. . . . . . . . . .

15 11 9

32 43 110

The high incidence of tuberculosis a n d u n d e r n o u r i s h m e n t in our c o u n t r y is reflected in the above table as also the history of recurrent diarrhoea in an

34

THE BRITISH HOM(EOPATHIC JOURNAL

appreciable n u m b e r of families. This explains w h y Tuberculinum a n d Psorinum are extremely useful as i n t e r c u r r e n t remedies i n the t r e a t m e n t of chronic diarrhoeas b u t t h e y were n o t used d u r i n g acute stages. THE

FEEDING

BOTTLE

T h e s t u d y of the problem of diarrhoea should embrace all the possible causative factors. P a r t i c u l a r s regarding boiling of the feeding bottles a n d vessels were collected i n 439 cases i n the age groups from b i r t h to 5 years a n d these details are given i n the following table: TABLE 5 No. of C a s e s Not boiled _ . . . Boiled once a day" .. . Boiled twice a day . . . Boiled thrice a day . . . Boiled four times a day Boiled with every feed

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . .

342 41 23 15 12

Total

9

Percentage 78"0 9"3

6

5"2 3"4 2"7 1-4

439

100- 0

I t is seen t h a t i n 78% of the cases the feeding bottles a n d vessels were n e v e r boiled at all. N e a r l y 4 0 % of these bottles were n o t of the c o n v e n t i o n a l t y p e a n d therefore could n o t be washed thoroughly. This resulted i n the creation of small colonies of bacteria i n vitro. This is a n i m p o r t a n t cause of r e c u r r e n t diarrhoea i n our children a n d m u s t be carefully looked i n t o w h e n t r e a t i n g such cases. SEASONAL

VARIATION IN

RECURRENT

DIARRH(EA

I t was decided to find out the seasonal v a r i a t i o n i n r e c u r r e n t diarrhoea which m i g h t provide a n i m p o r t a n t clue to a group of remedies suitable for r e c u r r e n t or chronic diarrhoea. The following t a b l e contains these details: TABLE

6

Exacerbation in: Summer Winter Monsoon

No. of cases

. . . . . . . . . . . . . . . . . . To~al

....

4 1 6 11

I t is seen t h a t o n l y i n 11 cases, i.e. i n 2 . 2 % of the t o t a l n u m b e r of cases, definite seasonal v a r i a t i o n was present. This adds to the difficulty i n finding a s i m i l i m u m i n cases of chronic diarrhoea. VITAMIN DEFICIENCY M a l n u t r i t i o n a n d r e c u r r e n t diarrhoea form a vicious circle, one giving rise to the other. Chronic diarrhoea leads to m u l t i p l e deficiencies, m a r a s m u s a n d Kwashiorkor, especially i n poorer classes. The following table illustrates this point.

ACUTE

DIARRH(EA

IN

35

CHILDREN

TABLE 7

Deficiency

No. of

Severe anmmia .. Vitamin A deficiency .. Vitamin B deficiency . . Vitamin C deficiency .. Vitamin D deficiency .. Marasmus and Kwashiorkor Total

.

.

.

,~

~ .~ .~

~

.~

.

.

.

.

.

.

.

Percentage of Total

Cases

.. .. .. .. .. ..

56 44 30 18 15 60

I I "2 8"8 6"0 3'6 3-0 12"0

9

223

44- 6

In Bombay a good number of m y senior homceopathic colleagues scorn at the suggestion of treating severe deficiencies according to the modern concept and even regarding diet they would discuss nothing but avoidance of coffee and tea. The above table illustrates the condition of our children suffering from chronic diarrhoea. Unless the deficiencies are treated with suitable diet or multivitamin and iron preparations, our remedies do not act well. Ideally these children should get natural and balanced diet, but owing to the poor economic conditions this is not possible or practicable in a very large number of families in our country. I t is therefore essential to supplement the poor diet with concentrated tonics. This is just like supplying enough food to a hungry child and giving vitamins, etc., to children with gross deficiencies at least till they are brought to the normal optimum level is a logical, natural and ideal method which cannot offend the homoeopathic method of therapeutics. In fact, this method was found to be unavoidable to achieve good results and this will be the subject of another paper on "Chronic Diarrhoea". Supplementary vitamins, etc., ought to aid the Vital Force along with the indicated remedy in the circmnstances described above. TABLE 8

Age at which the first attack Birth to 3 months 3 months to 6 months 6 months to 1 year 1 year to 2 years 2 years to 5 years Total

.

.

. . . . . .

. . . . . .

. . . . . .

. . . . . .

appeared

. . . . . .

. . . . . .

. . . . . .

No. of Cases

. . . . .

. . . . .

. . . . .

46 102 126 44 36

.

.

.

354

Perceni~age 12.8 28-9 35.6 12.5 10.2 ~

I00.0

I t is seen that in 28 "9~/o children the first attack of diarrhoea appeared between 3 and 6 months of age and in 3 5 . 6 % children between 6 months to 1 year. This

underlines the need for proper constitutional treatment to be carried out early in infancy, and this should succeed in preventing diarrhoea and its consequences at least in a majority of children. DIARRH(EA

AND

FEEDS

All artificial b a b y foods are forbidden b y m a n y homoeopaths who insist on feeding babies on fresh cow's or buffalo's milk both of which are difficult to obtain

36

THE

BRITISII

I-IOM(EOPATIIIC

JOURNAL

in t h e " n a t u r a l " form. W i t h a view to finding o u t the facts in this respect a n d also about, t h e general belief t h a t diarrhoea occurs less f r e q u e n t l y a m o n g breastfed babies, f a c t u a l i n f o r m a t i o n a b o u t feeds was collected in 212 cases. This is t a b l e d below: TABLE 9

Type of Food

No. of Cases I

Breast milk . . . . .. Breast and other milk . . . .

91

73 8 32

Powdered milk . . . . . . Buffalo's milk toned milk (equal parts skimmed milk and buffalo's milk) .. ~ow's milk . . . . . . Total

. . . . . .

~

I

I! i I I

212

Recovered

Died

Percentage

81 68 7 29

10

11.0

5 1 3

0 20.0

3

4 192

6.8 12"5 9"4

20

9.4

I t is seen from t h e a b o v e t a b l e t h a t t h e incidence of diarrhoea is n o t high in children fed on artificial a n d o t h e r t y p e s of m i l k as c o m p a r e d to those fed on b r e a s t mille. F u r t h e r , t h e r e is no significant v a r i a t i o n in t h e m o r t a l i t y rates.

PRESEI~TING

SYMPTOMS

AND

REMEDIES

USED

T a b l e 10 c o n t a i n s p r e s e n t i n g s y m p t o m s a n d remedies used. The following are t h e i m p o r t a n t d e d u c t i o n s from t h e table. Arsen. alb. T h e general i n d i c a t i o n s for this r e m e d y h a v e been confirmed. H o w e v e r , certain a,~peets need some c o m m e n t . Ars. has c h a r a c t e r i s t i c a l l y foul-smelling stools w i t h b l o o d a n d m u c u s whereas in 331 cases t h e stools c o n t a i n e d n e i t h e r a n d 251 cases d i d n o t h a v e foul stools. This was p r o b a b l y due to the fact t h a t these children h a d been t r e a t e d b y others w i t h a n t i b i o t i c s p r i o r to a d m i s s i o n to t h e nursing homes. The n a t u r e of stools a t t h e onset p r i o r to a n y t r e a t m e n t , of course, would be useful b u t in a m a j o r i t y of cases i t is n o t possible t o get t h e correct h i s t o r y in this respect. This a g a i n a d d s t o t h e difficulties in o b t a i n i n g t h e similimum. I n 42 eases stools were sour smelling a n d stools were n o t a c r i d in 359 cases, b u t these factors d i d n o t c o n t r a - i n d i c a t e Arsenic. I n 36 cases worms were p r e s e n t in t h e stools a n d this confirms t h e i n d i c a t i o n for Arsenic in " c o m p l a i n t s from worms". F u r t h e r , it will be n o t e d t h a t Arsenic cases h a d v o m i t i n g of small as well as large q u a n t i t i e s a n d also no vomiting. Convulsions were seen in 4 cases, "desire t o be u n c o v e r e d " in 9 cases, s y m p t o m s which are n o t g e n e r a l l y e x p e c t e d u n d e r Arsenic. I t is interesting to note t h a t all the cases of p a r e n t e r a l diarrhoea occurring in bronchitis a n d p n e u m o n i a were covered b y Arsenic. I n 8 cases " e x p o s u r e to the s u n " was t h e p r e c i p i t a t i n g factor a n d 5 cases h a d "desire for cold d r i n k s " . B o t h of these do n o t g e n e r a l l y suggest Arsenic a t least in acute conditions. I t was n o t possible to get a s i m i l i m u m in most of the cases a n d a f t e r s t u d y i n g t h e first 100 cases, the following simple indications were selected for Ars. alb.

37

ACUTE DIARRtt(EA IN CHILDREN

w h i c h h a v e p r o v e d t o b e n e a r l y i n f a l l i b l e . T h e s e i n d i c a t i o n s a r e very useful in the

absence of a similimum. 1 2 3 4

Irritability or drowsiness Small stools with or without blood or foul smell Severe dehydration 0liguria or anuria

Verat. alb. All t h e 111 c a s e s t r e a t e d w i t h t h i s r e m e d y h a d l a r g e a n d w a t e r y s t o o l s , i n c l u d i n g 5 cases w i t h "rice w a t e r s t o o l s " . V o m i t i n g also w a s p r e s e n t i n all t h e cases. TABLE 10 Cases covered b y Symptoms present

Ars. alb.

Verat. alb. Calc. phos.

STOOLS

1 2 3 4 5 6 7 8 9 l0 !1 12 13 14 15 16 [7 38

Large a n d w a t e r y .. Small . . . . . . Rice w a t e r .. Diarrhoea teas'eel .. W i t h f r a n k blood .. With mucus . . . . W i t h o u t blood or m u c u s :Foul smelling .. Sour smelling .. W i t h o u t a b n o r m a l smell Yellow . . . . Brownish . . . . Green . . . . . . Black . . . . . . Acrid . . . . . . N o t acrid . . . . Gushing . . . . Worms . . . .

[9 V o m i t i n g small quantities . . . . ,)0 V o m i t i n g large quantities . . . . ,)1 1~o v o m i t i n g . . . . . . . . . ,)2 V o m i t i n g ceased . . . . . . . ,)3 I r r i t a b i l i t y . . . . . . . . . .)4 Drowsiness . . . . . . . . .)5 Convulsions . . . . . . . . . .)6 Cold extremities Cold sweat on forehead .)8 Cold s w e a t all over . . . . . . .)9 Desire to be covered . . . . 30 Desire to be uncovered . . . . 31 Sensation of b u r n i n g . . . . ~2 Oliguria or a n u r i a . . . . . . . |3 H i s t o r y of colds and cough . . . . . ~4 H i s t o r y of bronchitis . . . . ~5 H i s t o r y of p n e u m o n i a . . . . . ~6 H i s t o r y of measles w i t h i n 15 days prior attack . . . . . . . . . . 17 H i s t o r y of p a r t a k i n g of cold drink ~8 H i s t o r y of exposure to the s u n . . . ~9 Desires cold drinks . . . . ,0 Desires w a r m drinks .. :1 V o m i t s soon after drinking .. 2 Distension of a b d o m e n .. 3 Severe d e h y d r a t i o n . . . . 4 :Fever . . . . . . . . . . .

0 164 0 210 29 14 331 81 42 251 53 231 4 86 15 359 3 36 60 36 98 108 111 210 4 39 0 2 16 9 3 83 52 9 14 3

. . . .

. . . . . i!

1060005

"

i

0 111 7 39 65 61 1 49 0 3 108 111 3

1 13 11 4 0 6 0 9 0 0 15 15 0

20 108 0 55 4 8 3 15 3 1 2 7 0 6 0 0 0

0 0 0 15 14 0 0 0 2 0 0 0 0 0 0 0 0

0 2 1 2 4 62 0 0 41

0 0 0 0 0 0 15 0 11

to the .

.

!

13 11 8 5 8 142 0 251 80

THE B R I T I S H H O M ( E O P A T H I C J O U R N A L

38

H o w e v e r , o n l y 3 c a s e s h a d " c o l d s w e a t s o n t h e f o r e h e a d " w h i c h is s a i d t o b e a n i m p o r t a n t c h a r a c t e r i s t i c o f t h i s r e m e d y . 15 c h i l d r e n h a d " c o l d e x t r e m i t i e s " . I n 61 c a s e s s t o o l s w e r e y e l l o w a n d i n 49 c a s e s t h e y w e r e g r e e n . T h e f o l l o w i n g s i m p l e i n d i c a t i o n s w e r e s e l e c t e d a n d f o l l o w e d i n all t h e c a s e s a f t e r s t u d y i n g t h e f i r s t 50 e a s e s : 1 2 3 4

Large w a t e r y stools with or w i t h o u t foul smell Stools gr(~nish or yellowish Severe v o m i t i n g or h i s t o r y of severe v o m i t i n g Mild t o m o d e r a t e d e h y d r a t i o n

Calc. phos. One does n o t generally t h i n k of this r e m e d y in a c u t e a n d severe diarrhoea. I n all t h e 15 c a s e s s t o o l s w e r e l a r g e a n d w a t e r y , v o m i t i n g h a d c e a s e d a n d t h e c h i l d r e n w e r e i r r i t a b l e . T h e s e w e r e t h e c a s e s w h e r e Verat. alb. h a d a c t e d p a r t i a l l y a n d f o u l d i a r r h o e a p e r s i s t e d . All o f t h e s e c a s e s h a d d i s t e n s i o n o f t h e a b d o m e n w h i c h is c o n t r a r y t o its u s u a l i n d i c a t i o n " s u n k e n a b d o m e n " . T h e f o l l o w i n g i n d i c a t i o n s w e r e s e l e c t e d f o r Calc. phos. i n s e v e r e d i a r r h o e a : l 2 3 4

Irritability S t o o l s large, w a t e r y - - m a y History of vomiting Distension of abdomen

b e foul s m e l l i n g

T a b l e 11 i l l u s t r a t e s w h y t h e a b o v e i n d i c a t i o n s w e r e s e l e c t e d f o r t h e r e s p e c t i v e remedies. T h e p e r c e n t a g e s in t h i s t a b l e a r e w o r k e d o u t o n t h e t o t a l n u m b e r o f c a s e s c o v e r e d b y e a c h o f t h e r e m e d i e s o u t o f t h e t o t a l o f 500 c a s e s i n o r d e r t o s h o w t h e frequency of occurrence of different symptoms under the respective remedies. O u t o f t h e t o t a l o f 500 cases, 374 w e r e c o v e r e d b y Arsenic, 111 b y Verat. alb. w h i l e Calc. phos. w a s i n d i c a t e d i n 15 cases. I t is a l s o n e c e s s a r y t o c o m p a r e t h e TABLE 11 Cases covered by

1

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Irritability .... i Drowsiness .... I Stools small .... ', Stools large, watelT " 9I Stools foul smelling .. Stools without abnormal smell .. .... ' Stools yeUow "" "i Stools green .. Stools with blood . StooLs with mucus " "ql Stools without blood or: mucus .... .. History of vomiting in large[ quantity . . . . . . I Distension of abdomen . .I Dehydration severe .. ! Dehydration m i l d t o ~, moderate . . . .. . . ()liguria or anuria. " "i

Verst.

% [Celt. p.

Ars.

% 29.7 56.1 43' 32-0 23.2

4 8

,

111 210 164 -87

316 120 62 30 15

251 53 4 2 14

67' 1 14.1 1 90 77"5 37"4

65 61 49 ---

58-6 54.9 44.1

455

331

88'5

111

100- 0

144 15 404

36

29"6

108

97-2

354

94.6

50

45.0

96 89

20 83

5' 3 22' 1

76 6

68"4 5-4

i

%

3"6 7'2

14

93"3

95" 5 6'3

15 I1

100-0 7.4

6 9 1 1

40.0

13

86-6

15

100.0

m

60' 0 6-6 6.6

m

ACUTE

DIARRH(EA

IN

CHILDREN

39

frequency of occurrence of symptoms under different remedies with the total number of cases in which the respective symptoms appeared. EMPLOYMENT

OF REMEDIES

All the remedies were administered in the form of solutions. 20 pills (No. 20) were added to 1 oz. of distilled water and 4 drops of this solution constituted a dose. I n severe cases remedies were administered every haft-hour, and in mild to moderate cases the repetition was 2-hourly on the first day. A rough routine had to be laid down because of m a n y practical difficulties of nursing and management in nursing homes. In all the cases remedies were repeated 3-hourly on the 2nd and the 3rd day, 4-hourly on the 4th day and were then gradually omitted. No aggravation or harmful effects were observed in any of the cases. I n fact, on the first and the second day it was noticed that frequent repetition was absolutely necessary to bring about a rapid recovery. With less frequent repetition, reaction was poor in severe cases and recovery was comparatively delayed. A majority of the cases were completely cured in 4-5 days. Malnourished and marasmic children lingered and could be discharged after 10-15 days' treatment though the diarrhoea was controlled in 3-4 days in these cases. THE

POTENCY

Ars. alb. was used in the 10M and 50M potencies, the former in mild cases and the latter in moderate to severe cases. Verat. alb. was found to be effective in the 50M potency. Calc. phos. which was always used after the diarrhoea had been partially controlled always acted in the 200th potency. Very high potencies and frequent repetition MUST be the rule in acute and severe diarrhoeas, according to our experience. OTHER REMEDIES Seven cases were in a severe state of shock and Ars. alb., Verat. alb. and Carbo. veg. failed to elicit any immediate response. With considerable reluctance, I had to give these children hydrocortisone and noradrenaline in addition to intravenous fluids which were administered in all the third degree eases. Ars. alb. also was administered along with the above in drop doses. Administration of remedies through oftaction and implantation of pills under the eyelids and the tongue did not have any effect in these cases. After the first 24 hours only homceopathic remedies were administered in all these cases. Two children died and five recovered. These results are comparatively good in this group; all the five children who recovered had received the combined therapy and the two who died were under homoeopathic remedies alone. Further, with modern therapy alone the mortality in such moribund cases is higher. The inference is clear. However, the fact remains t h a t 493 out of 500 cases of severe diarrhoea could be managed with homoeopathie treatment alone. MAINTENANCE

OF FLUID

AlqD ELECTROLYTE

BALANCE

Workers in other fields report t h a t in children with severe dehydration the maintenance of fluid and electrolyte balance is the most important p a r t of the treatment. Whenever a child with diarrhoea is brought in a moribund state, i.e. a picture of shock with cold extremities, very feeble or impalpable pulse, sunken eyeballs with dried mucus on the cornea, semi-conscious or unconscious state, it is important to push in intravenous fluids instantly and thus treat the state of

40

TIlE

BRITISH

HOM(EOPATIIIC

JOURNAL

shock and peripheral failure and bring him to a state in which he can respond to the treatment. Thanks to Dr Athavale, I had the privilege of seeing what great and kind nature can do in such cases. A dying infant recovered completely in 48 hours following administration of correct intravenous fluids only. This child was not given any medicines! And this case has not been included in the present series. However, being a staunch (95O/o)homoeopath, I wish to verify the above fact. In 2 moribund cases the indicated remedies only were administered--drop by d r o p - - b u t I was shocked to see these children die within 2 and 4 hours respectively during which period I was sitting at the bedside anxiously expecting dramatic results. In these cases, because of the loss of vital fluids, circulatory failure and shock, the vital force is almost extinct and is unable to react to the remedial stimulus. This underlines the necessity of bringing the patient out of the shock state first by administering intravenous fluids in proper proportion and quantity thereby reviving the failing circulation and in turn the sinking vital force of the patient. This is very logical. In severe cases of diarrhoea with second or third degree dehydration, there is a great loss of body fluids and unless these are replaced no remedy can stimulate the vital force which depends on the vital fluids. Remedies cannot replace the lost fluids which should be administered either orally where possible or parenterally where the patient is vomiting or cannot swallow. Some responsible homoeopaths of Bombay have been teaching that the indicated remedy is the only thing that is needed and they laugh and scorn at the above auxiliary therapy. Theoretical discussion cannot alter facts. DIET

In third degree eases and in eases with vomiting parenteral alimentation was maintained till they improved. In first and second degree cases, fluids were administered orally. Later in all cases weak tea, ripe bananas, Lactodex, pomegranate and apple juice were gradually prescribed. Older children were allowed light diet 24 hours after the diarrhoea had ceased. DEHYDRATION

S

Dehydration implies a negative water and electrolyte balance and is present in every case of diarrhoea. In children, especially in the younger age group, dehydration sets in very rapidly compared to adults. In adults, dehydration rarely presents a serious problem but a child with severe vomiting and diarrhoea may die of dehydration within 24 hours of the onset of the illness if not treated properly. The cases of rapid and severe dehydration in infants are: (1) Large fluid requirements, e.g. infants require about 150 ce fluids per kg body weight compared to the adult requirement of 50 ce per kg body weight per day; and (2) Smaller storage capacity which is approximately one-third that of adults, i.e. the reserve fluids of the body in a 8-9-months-old child are enough to provide daily fluid requirements for 2 days only whereas an adult can draw on his reserve fluids for 7 days. Recognition of different degrees of dehydration is extremely important and this can be done with the help of table 12. After assessing the degrees of dehydration, a proper line of treatment was mapped out. In addition to the indicated remedy, oral fluids should be given in first and

41

A C U T E D I A R R H ( ~ A IN C H I L D R E N TABLE 12 MILD First-degree

Symptoms

i i MODERATE ~i. Second-degree

1 General appearance and Cross, fretful, sleeps I More restless, and behaviour fitfully I sleeps fitfully. High !pitched wailing cry. i Pale, anxious face 2

Thirst

Thirsty

Limp, quiet, apparently unconscious. Unable to cry :.

Often extreme but Thirst may not be vomits i apparent owing to I general condition or may refuse feeds

3 Mouth

"1!Dry lips and bright i Very drv lips red, dry furred ' " " tongue

4

"-Bright

Eyes

SEVERE Third-degree

Tongue dry and coated, looks small. ' Terminal cyanosis

Sunken

Deeply sunken, Dried mucus on the cornea

iJ 5

Skin

6

Fontanelle

Dry. Elasticity normal I Slightly sunken

7 Urine output

8

Elasticity nished

dimi-!Elasticitymarkodly diminished

Sunken-{-

Sunken + +

" Oliguria may be Greatly reduced present and might not have been notice__d by__parents

Weight loss

2~--5~o o f I weight

body

5-10% weight

of

body

i

Oliguria--anuria

i J J

More than 10% of body weight

second degree cases and all the third degree cases must receive intravenous fluids. A very small percentage of the third degree cases like the 7 cases already referred to m a y require blood plasma transfusion and combined therapy. These are, however, the fulminating cases. With only the indicated remedy the results are bound to be extremely poor, especially in the third degree cases. Table 13 contains details of the cases treated under different age groups and degrees of dehydration with the remedies used in each group. Many deductions can be drawn from this table. The most important points to note are that severe dehydration was present in 329 cases, i.e. 65.8% of the total number of cases and that moderate to severe dehydration was present in 135 cases, i.e. 27~ of the total cases. Some of the cases classified under second degree were in fact on the border line of the third degree. I t is seen that in 374 cases, i.e. 74-8%, Ars. alb. was indicated and in most of these cases the simplified indications given under Table 10 were relied on. Verat. alb. was similarly selected in 111 cases, i.e. 22-2%. I n 38 cases Ars. alb. was given after Verat. alb. when the latter remedy had controlled the diarrhcea but stopped acting further. Such cases are included under Ars. alb. in the above table. COMPLICATIOI~S

AI~D

TREATMENT

Paralytic ileus or severe distension of the abdomen was a serious complication in 8 cases and was caused by toxsemia or electrolytic disturbances. Opium 1000 4A

42

T H E B R I T I S H HO~CI(EOPATHIC J O U R N A L TABLE 13 Degree of Dehydration

B-1M

1M-6M

i

Remedies with cases Total II Remedies with cases

v 2

v-9

C- 2

A- 4 C- 0

AC-

9

6

V- 1 A-2 C-3

V- 1 A- 2 C-0

1Y-2Y

0 2

C- 2

11

9

C-0 1

10 A - 37 C- 1

30

48

18

I9

12

V-29 A-24 i C-0

V - 12 A-107 C- 0

V-6 A-56 C- 1

V-5 A-39 C-0

V-3 A-38 C-0

V-0 .4_-6 C-0

63

44

41

6

53

8

8

V-8 A-8 C-2

2Y-5Y I 5Y-10Y 10Y-12u

A-20 C-2

V-

Total III Remedies with cases

6M-1Y

V-

A-12 C-0

C-0

V-0 A-2 C-0

J_ I

Total

3

i

53

119

]

Total n u m b e r of all cases

4

18

i i!

-I

J

89

178

90

64

Note: B: :Birth; M: Month; Y: Year; A: Arsenic alb.; V: Verat. alb.; C: Calc. phos. Cases with lEt degree dehydration Cases with 2nd degree dehydration Cases with 3rd degree dehydration

. . . . . . . . . . . . . . . . . . . . . . . . Total

Total n u m b e r of Arsenic cases .. Total n u m b e r of Verat. alb. cases Total n u m b e r of Calc. phos. cases

. . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . Total

. . . . . .

36 135 329 500

374 111 15 500

and 10M selected in one case on the symptom totality did not act and the child d i e d . Carbo reg. 2 0 0 a n d 1000 a l s o s i m i l a r l y d i s a p p o i n t e d a n d t h e s e c o n d c h i l d w a s l o s t . A c o m b i n a t i o n o f ArE. alb. CM, Opium 1000 a n d Calc. phos. 2 0 0 - - 2 0 p i l l s o f e a c h t o 3 oz. o f w a t e r - - 2 d r o p s e v e r y h o u r , s a v e d 5 c h i l d r e n a n d t h e mortality in this group came to 37.5%. Unconventional methods may be e s s e n t i a l i n m a n y s u c h c o n d i t i o n s w h e r e a s i m i l i m u m is e i t h e r a b s e n t o r n o t available. Homceopathy can be developed in many ways and orthodoxy should not come in the way. T o x m m i a , h i g h f e v e r , h y p e r n a t r e m i a o r v a r i o u s effects o f d e h y d r a t i o n o n t h e b r a i n w e r e t h e c a u s e s o f c o n v u l s i o n s i n 7 cases. O n e c h i l d d i e d t h o u g h t h e i n d i c a t e d r e m e d y h a d s t o p p e d t h e d i a r r h o e a a n d v o m i t i n g . Cup. met. 1000 c l a i m e d o n e life a n d Bell. 1000 a n o t h e r . I n t h e r e m a i n i n g 4 cases, Bell. t 0 0 0 w a s mixed with the indicated remedy the moment convulsions appeared and out of t h e s e 4 cases 3 r e c o v e r e d a n d 1 d i e d . T h u s , t h e m o r t a l i t y i n t h i s g r o u p s t a n d s a t 57-1%, which might have been much lower had the mixture therapy been e m p l o y e d i n a l l t h e cases.

43

A C U T E D I A R R H ( E A IN C H I L D R E N RESULTS The following table sums up the results of the treatment: TABLE 14 Recovered Degree of Dehydration I II III

. . . . . . . . . . . . . . . . . . Total

..

Died

No.

%

No.

%

36 125 307

100-0 92.6 93.3

10 22

7.4 6" 7

468

32

Total Number

Percentage of Total

36 135 329

7.2 27-0 65-8

500

100.0

OveraHmortality: 6 . 4 %

Some of t h e 2nd degree cases were on the b o r d e r line of 3rd degree a n d this explains the higher mortality in the former group. T h i s t a b l e s h o w s t h a t 7 - 2 ~/o o f t h e c a s e s w e r e m i l d , 27 0/0 m o d e r a t e a n d 65.8~/o w e r e s e v e r e a n d t h e o v e r a l l m o r t a l i t y is 6 - 4 % w h i c h c o m p a r e s v e r y f a v o u r a b l y with the mortality rates in general hospitals in the best centres which vary from 8 % t o 11~/o. I t m a y b e p o s s i b l e t o b r i n g d o w n t h e a b o v e m o r t a l i t y w i t h t h e above methods in a well-equipped homceopathic general hospital.

INVESTIGATIONS I n s p i t e o f a s t r o n g d e s i r e i t w a s n o t p o s s i b l e t o d o all t h e n e c e s s a r y i n v e s t i g a t i o n s . H o w e v e r , s t o o l s w e r e e x a m i n e d i n 140 c a s e s a n d t h e f o l l o w i n g b a c t e r i a were isolated: T~B~L~. 15

E. coli . . . . . . E. freundii . . . . Paracolon . . . . . . A. *erogens . . . . Ps. mrogenosa . . . . Pr. mirabflis . . . . Klebsiella . . . . S. paratyphi . . . . Shig. sonnci . . . . Pr. Morgan .... Shig. Shiga . . . . L. F. E. Coli . . . . Shig. Flexner .... Alk. fmcalis . . . . A. cloacae .. Gas bacteria . . . . Staphy. aureus . . . . V. cholera . . . . . . Pr. vulgaris . . . . N. L. F. paracolon ..

.

..

9 Number

%

119 18 17 12 11 6 5 3 3 3 2

85"0 12"8 12.8 8.5 7.2 4.3 3-5 2.1 2.1 2.1 1.4 1.4 1-4 1-4 0-07 0-07 0.07 0-07 0-07 0.07

2 2 1 I 1 1 1

S e r o t y p i n g o f E . coli w a s d o n e i n 25 c a s e s a n d t h e f o l l o w i n g a r e t h e r e s u l t s : 4B

44

THE

BRITISH

HOM(EOPATHIC

TABLE

JOURNAL

16

:No. of Cases E. coli

[9

.~ .~

020 086

9

0111

9

0112

9

0127

7

Total

At the present time, these investigations do not appear to be useful for homoeopathie prescribing. However, b y good observation we m a y be able to develop definite indications based on pathological findings. At present we are using only macroscopic indications such as presence of blood and mucus of Merc. sol. and Merc. cor. and while comparing these remedies, we even stress the presence of more blood in favour of Merc. cor. Similar indications can be developed further on the microscopic findings such as red blood cells, etc. After some years it m a y be possible to establish homoeopathic indications based on the positive organisms in relation to modalities, characteristics, etc., which m a y be very useful. COMMENTS

ON

PROGNOSTIC

POINTS

Fever: I n nearly 74% of the cases, fever was absent on admission to the nursing homes, although diarrhoea is presumed to be infective in origin and infection should give rise to fever. I n the newborns (babies up to the age of one month), it is a general observation t h a t fever m a y be absent even with severe infections like pneumonia but in older children with diarrhoea the condition of collapse was probably the cause of absence of fever. Soon after initial treatment, the temperature shot up in m a n y cases and this was considered as a good reaction and not an "aggravation". I n cases with high fever the mortality was slightly higher. C.N.S. Signs and Oliguria: Mortality was also higher among children with oliguria, drowsiness, irritability, convulsions and cold extremities. Cold, Cough, Measles: I n cases where recent history of measles or cold and cough was present, the mortality was slightly lower. This m a y not have any significance. Vomiting: I n cases with vomiting, the mortality was slightly higher. SUMMARY

500 cases of acute gastro-enteritis in children are presented. All the cases were treated with homoeopathic remedies in private nursing homes during the period from J a n u a r y 1958 to December 1962. The chief causes and precipitating factors of acute diarrhoea, seasonal variation, monthly distribution of cases, frequency of recurrent attacks in children and deficiencies in the victims of chronic diarrhoea are all discussed. Presenting symptoms under all the cases are classified under respective remedies used and a few simple and definite indications in acute diarrhoea for each remedy have been established 9 The problem of dehydration and the importance of its treatment with

ACUTE DIARRH(EA IN CHILDREN

45

i n t r a v e n o u s or oral fluids has been t h o r o u g h l y discussed. A l l t h e cases h a v e been classified a n d discussed u n d e r different degrees of d e h y d r a t i o n . All t h e cases h a v e been t r e a t e d w i t h homceopathic remedies. Seven cases in t h e series were in a s t a t e of severe shock a n d o n l y in these cases n o r a d r e n a l i n e a n d h y d r o c o r t i s o n e h a d t o be used in a d d i t i o n t o t h e i n d i c a t e d r e m e d y . C o m m o n complications a n d t h e i r t r e a t m e n t a n d c e r t a i n p r o g n o s t i c p o i n t s h a v e b e e n discussed. A m e t h o d of a d m i n i s t r a t i o n of 2 or 3 remedies in c o m b i n a t i o n u n d e r e x c e p t i o n a l c i r c u m s t a n c e s has been discussed a n d a d v o c a t e d . Results of e x a m i n a t i o n of stools in 140 cases a n d t h e i r possible relation t o homceopathic i n d i c a t i o n s has been discussed. T h e overall m o r t a l i t y is 6 . 4 % which compares v e r y f a v o u r a b l y w i t h t h e m o r t a l i t y in o t h e r hospitals. ACKNOWLEDGEMENTS I a m grateful to D r V. B. A t h a v a l e , M.D., D.C.H. B o m b a y , for his k i n d coo p e r a t i o n a n d advice which e n a b l e d m e to work, s t u d y a n d b r i n g o u t this p a p e r . M y sincere t h a n k s are due t o Drs (Miss) S. Ezekiel, L.C.E.H., S. R. K h e k a l e , B.A.M.S., B. D. D a n d a v a t e , B.A.M.S., a n d H. Azgaralli, B.A.M.S., who k i n d l y assisted m e in a n a l y s i n g t h e d a t a . REFERENCES 1 Athavale, V. B., M.D., D.C.m, "Present Day Illnesses in Indian Children". Curre~ Medical Practice, vol. 6, no. 6, June 1962, pp. 289-99. Current Technical Lit. Co. Pvt. Ltd., Bombay. 2 Borland, D. M., Children's Types. Brit. Horn. Ass. London. 3 Athavale, V. B., M.D., D.C.m, Post-Graduate Lectures on Diarrhwa and Dehydration. Under publication. Bombay. 4 Athavale, V. B., and Pai, P. N., "Management of diarrhoea". The Indian Practitioner. Under publication. Bombay.