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Treatment of acute infantile diarrhea with carob flour (Arobon)
T R E A T M E N T Oh' A C U T E I N F A N T I U E I ) [ A R R t I E A W I T I t CAROB F L O U R (AROBON) P ~ B L O U . ABI,;I,I~A, M . ] ) . FRESNO,
CUTE diarrhea, despite progress in t h e r a p y during the last decade, constitutes a m a j o r threat to infants and children. Because of the high morbidity and mortality, the diarrheas account for a large part of the pediatric ward admissions. In the state of California, infantile d i a r r h e a ranked sixth among the leading causes of infant mortality in 1945.1 I n addition to the applieation of the basic principles of fluid balance and electrolyte metabolism in the management of diarrheal disorders, a constant search for substances that can be used to hasten the amelioration of s y m p t o m s has been going on. The efficacy of certain fruits in the treatment of diarrhea has been a m a t t e r of common knowledge for m a n y years. The apple and banana have been tried and found to have favorable results and each has its advocates. 2 I n 1949 Smith and Fischer a reported the use of earob flour taken from the f r u i t of the earob tree, a leguminous plant which is native to the shores of the Mediterranean. This f r u i t (variously called St. John's bean, locust bean, Ceratonia siliqua) is a bean-shaped pod about 12 to 20 era. long by 2 era. wide. The pod contains a sweet pulp, rich in sugar (49 per cent) and low in protein (4 per cent) and very rich in lignin which is believed to be responsible for its unusual mechanical a n d detoxieating properties.
A
F r o m the General Hospital of F r e s n o County. l~resent a d d r e s s : Boston City Hospital, Boston, Mass. 182
CALIF.
Title purpose of the present study was to deternfine whether the favorable results in the management of the diarrheas with the use of carob flour (trade n a m e - - A r o b o n ) reported by Smith and Fischer a in 1949 and by Plowright 4 in 1951 could be confirmed by reviewing a larger number of cases. CLINICAL MATERIALS AND METHODS
The General Hospital of Fresno County located i n the center of the agricultural San Joaquin valley of California itas admitted to its pediatric service an average of 455 cases of acute infantile diarrhea annually for the past five years (1947 1951). Since the latter part of 1949 the pediatric service has been using earob flour (Arobon) as an adjunct in the dietetic treatment of diarrheas. Over a thousand eases of diarrhea have been tried on the carob flour regime. Of this number 300 cases were selected, and for control, 300 patients treated previously (1948) on a similar regime but without Arobon. Cases of equal or similar severity were selected from both groups. The ease histories,, doctor's orders, course in the hospital, and duration of treatment were scrutinized in order to p r o p e r l y classify the diarrheas. E x c e p t for the addition of Arobon to the dietetic regime, the treatment was similar in both groups. Because of the high costs of hospitalization, criterion for admission was generally as follows: (1) evidence of acidosis, (2) evidence of infection complicating the diarrhea, (3)
ABELLA:
INFANTILE
DIARRHEA
moderate to marked dehydration, (4) persistent v o m i t i n g accompanying diarrhea, and (5) failure to respond to treatnlent in clinic or outpatient department. F o r convenient evaluation the severity of the patient on admission was classified as follows: (1) Mild--diarrhea with little or no dehydration with carbon dioxide combining power over 35 vol. per cent. (2) Moderate--diarrhea usually accompanied by fever, moderate dehydration, and with carbon dioxide combining power of from 25 to 35 vol. per cent. (3) S e v e r e - diarrhea with extreme or marked dehydration, with carbon dioxide combining power below 25 vol. per cent, in moribund state or in extremis. Of the 600 cases reviewed, 44 per cent fell under the classification of " m i l d " diarrhea, 34 per cent were of "moderate" severity, and 22 per cent were in the "severe" group. Although the carbon dioxide combining power is one of the few objective measurements of the severity of the illness, it was taken in only a small group (6 per cent), perhaps because of the fact that there were not enough trained personnel to handle this laboratory procedure and so only the most necessary ones were taken. Frequently, however, t h e severity index could be welI defined clinically, i.e., the amount of acidosis is usually proportional to the amount of dehydration. In all eases studied it was routine procedure to have stool cultures daily for at least three days after admission. F o r those that were positive for Shigetla d*ysenteriae or of the Salmonella group, three negative stool cultures were reported before the patients were discharged. The ~ s u a ] admitting
AND
CAROB
FLOUR
183
laboratory studies, as a complete blood count and urinalysis, were done. P~an of Treatment.--The following is the regime used, the details modified according to the clinical symptoms, the duration, severity, and the objective laboratory findings: I. Period of Fasting: I t is usual to withhold all formula and oral medications for at least twelve hours, except in the mild eases without nausea or vonfiting and where hunger is evident. I f the child has not been vomiting, Ringer's-lactate or H a r t m a n n ' s solution is given every hour in amounts of 1 ounce and gradually increased by ~fie ounce until 3 to 4 ounces are tolerated. II. Feeding Plan: Guided by the patient's demonstration of tolerance to oral feedings, the earob flour, (Areben) preparation is then given (in the proportion of one-half of 10 per cent Arobon with one-half boiled skimmed milk) :in amounts according to the child's age. A f t e r the first formed stools, Arobon is then diluted with equal amounts of the "going-home formula," that is, one-half of 10 per cent Arobon and one-half of a 1:2 formula of evaporated milk. Then if the stools continue to be of satisfactory consistency, number, and volume, a straight "going-home formula" is finally givenP III. Parenteral Fluid Therapy: As soon as possible fluids are given either intravenously or by hypodermoelysis depending upon the amount of de* A 10 p e r c e n t s o l u t i o n A r o b o n i s p r e p a r e d b y a d d i n g 12 t a b l e s p o o n s f u l t o 32 o u n c e s o f water. Measure out Arobon into a dry pan a n d s t i r c o n s t a n t l y w h i l e p o u r i n g 10 o u n c e s o f cool sterile water (boiled previously f o r 10 minutes) onto the Arobon. The remaining amount of sterile water (22 ounces) is brought to a boil, the Arobon solution added t o it, a n d i t i s a g a i n b r o u g h t to a boil. As soon as the boiling point is reached, remove t h e f o r m u l a f r o m t h e fire, a l l o w i n g i t t o c o o l before pouring into the bottles.
184
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ABELLA:
INFANTILE
185
D I A R R H E A AND CAROB F L O U R
hydration, a c i d o s i s, or circulatory shock. The choice of fluids also depends to a great extent on the clinical picture. As soon as the dehydration and acidosis are corrected and when oral feedings are tolerated, p a r e n t e r a l fluids are discontinued in f a v o r of the oral route.
Practically the same regimen was followed in the control group of 300 cases reviewed (comprising the period f r o m J a n u a r y to December, 1948,, before the use of Arobon was instituted in the dietetic t h e r a p y ) , except for the fact t h a t in the feeding plan as soon as the infant's tolerance to oral feed-
9O 80 70
..y-
~60
g
5o
~4o
Ill
~30
10
3an,Feb, Mar, Apt, May, June July Au~Sept. Oc% Nov, Dec. Fig. 1 . - - S e a s o n a l incidence. 20
18 16 14
10 8 6 /+
b
0-1
2
4
5 M(~THS
6
7
8
9
~' AGE
I0
11
12 13over
Fig. 2.--Age incidence.
IV: Chemotherapy: W h e n the clinical picture or the results of the stool cultures and other laboratory studies indicate, antibiotics alone or in combination are used to control the infection.
ing was evident, the formula was changed f r o m Ringer's-lactate solution to boiled skimmed milk. This f o r m u l a was kept up until stools became formed and the strength of the milk was g r a d u a l l y increased until the
]$6
child was mula."
THE JOURNAL OF PEDIATRICS
on the
"going-home for-
RESULTS
Table I is a s u m m a r y of the data collected f r o m the two groups of cases. The data u n d e r subgroup A in this table shows quite a comparable course in both the Arobon and non-Arobon groups. There w a s 4.79 average n u m b e r of days p r i o r to admission in the Arobon group as compared to 5.41 days in the non-Arobon group. The Arobon group had 9.30 average number of stools p r i o r to admission comparable to 7.45 average of the nonArobon group. The percentage with bloody stools on admission together with the percentage of those with p a r e n t e r a l complications are still within the normal limits of deviation. The data u n d e r Results show the differences in the results of the two groups. The Arobon group shows that formed stools are observed a f t e r an average of 1.16 days as compared to 6.08 days in the group without Arobon. I t took only an average of 5.97 days before the "going-home f o r m u l a " was tolerated in the Arobon group compared to 9.18 days in the nonArobon group. Patients t r e a t e d without Arobon stayed an average of 3.33 days longer in the hospital and had 6 per cent more readmissions. D u r i n g their hospital stay the average weight gain of those on Arobon was 14 ounces compared to 9.87 ounces a v e r a g e weight gain of those treated without Arobon. A definite seasonal incidence was noted (see Fig. 1). The lowest number of diarrhea admissions were during the months of F e b r u a r y , March, and April. A gradual increase occurred d u r i n g the summer, and the peak was
reached during the month of November. A n a b r u p t drop is observed during the cold months of December and January. Significantly, this seasonal incidence coincides with the seasonal migration of large groups of m i g r a n t laborers who work the vineyards and pick the cotton fields. P e r h a p s because of their economic handicap, o r d i n a r y s a n i t a r y conveniences and precautions are forgotten and p r o p e r care of their infants and children is wanting. I t is f r o m these workers in the r u r a l areas that the m a i n body of our patients comes. The incidence of infantile diarrheas according to age in both the Arobon and non-Arobon groups is shown in Fig. 2. There is a comparable age incidence in both groups. There is a higher incidence in infants u n d e r 6 months (70.5 p e r cent) t h a n in those over 6 months (20.5 per cent) of age. Only 9 per cent were children over one year. DISCUSSION
F u r t h e r review of the literature on carob flour reveals its use originally b y Ramos and Ronzalen 5 of Spain during the Spanish Civil War. E u r o p e a n pediatricians soon f o 11 o w e d suit. Megevand and Riederer 6 r e p o r t e d favorable results in studies in Switzerland. N e y r o u d ~ and his colleagues f r o m their studies in B e r n concluded that the use of carob flour represents a considerable progress in the dietetic t r e a t m e n t of infantile diarrhea. Vianello 8 writing f r o m the Pediatric Clinic of Bologna, I t a l y , confirmed its antidyspeptic properties. I t would seem t h a t earob flour (Arobon) is effective in r a p i d l y cutring down the n u m b e r and improving the consistency of the stools and thus
ABELLA:
INFANTILE DIARRHEA AND CAROB FLOUR
preventing further electrolyte loss and metabolic derangement. Diarrhea patients tolerate simple carbohydrates and proteins well but fats poorly. Arobon, with its content of 49 per cent soluble carbohydrates (sucrose and reducing sugars) and 4 per cent proteins with only 0.5 per cent fats, provides a food which with its rich lignin and pectin content acts not only to detoxieate and constipate but also provides an adequate amount of calories (75 calories per ounce by dr y weight). On the point of acceptability to the patient, it was noted that those below 12 months took the formula containing Arobon contentedly. Three patients over 12 months of age refused the chocolate-colored Arobon solution. No evidences of toxicity or side effects were noted in the 300 patients on Arobon. CONCLUSION
From the above studies, it would seem that the use of carob flour (Arobon) has been of considerable value as an adjunct in the dietetic therapy of infantile diarrheal disturbances, both in terms of shortening the p e r i o d of hospitalization and shortening the duration of the disease. This does not, however, lessen the paramount role of the administration of fluids and electrolytes in the treatment of diarrheas. SUMMARY
1. A study is presented of 600 cases of acute infantile diarrhea admitted to the pediatric' service of the General
187
IIospital of Fresno County. Three hundred of these cases were selected from those treated witlh earob flour (Arobon) as an adjun6t in the dietetic therapy, while the other 300 cases were those patients treated without Arobon. 2. In a tabulated comparison the Arobon and non-Arobon groups present a similar picture. The results show significant statistical differences. 3. As an adjunct in the dietetic therapy of acute infantile diarrhea, carob flour (Arobon) is of considerable value in hastening cure and recovery. REFERENCES 1. From studies made by the Bureau of Maternal and Child Health, Division of Prev e n t i v e Medical Services: " I n f a n t Mort a l i t y in California, 1920-]945," California Health 5: 6, 9-30, ]947. 2. Fries, J. tL, Chiara, N. J., and Waldron, tg. J.: D e h y d r a t e d Banana in Dietetic :Management of Diarrheas of Infancy, J. PEDIAT. 37: 529~ 1950. 3. Smith, A. E., and Fischer, C. C." The Use of Carob Flour in the T r e a t m e n t of Diarrhea in I n f a n t s and Children, J. PEDIAT. 35: 422, 1949. 4. Plowright, T. I~.: The Use of Carob Flour in a Controlled Series of I n f a n t Diarrhea, J. PEDIAT. 39: 16, 1951. 5. Ramos, R., and Rozalen, 3/[.: U n Nuevo Alimento-Medlcamento: La t t a r i n a de Algarroba, Rev. espan, farIn, y terap. 21: 1339, 1941. 6. 3/[egevand, J., and Riederer, V. de" Un Nouvelle Therapeutique pour les Troubles Digestifs Graves des Nourissous (Dyspex)j Rev. m6d. de la Suisse l~om. 61: 330, 1941. 7. Neyroud~ 3/I.: Carob Flour, a N e w Antidiarrheic Medicine, Ann. paediat. 166: 113, 1946. 8. Vianello, A.: Carob Flour and I t s Antidyspeptic Properties, L a t t a n t e 18: 282 (May) 1947. 9. Albritton, E. C.: To E s t i m a t e ~ P for the Difference Between Two Means, Exper. Design & Judge. of Evid. 1: 2], 1946.
CUTE diarrhea, despite progress in t h e r a p y during the last decade, constitutes a m a j o r threat to infants and children. Because of the high morbidity and mortality, the diarrheas account for a large part of the pediatric ward admissions. In the state of California, infantile d i a r r h e a ranked sixth among the leading causes of infant mortality in 1945.1 I n addition to the applieation of the basic principles of fluid balance and electrolyte metabolism in the management of diarrheal disorders, a constant search for substances that can be used to hasten the amelioration of s y m p t o m s has been going on. The efficacy of certain fruits in the treatment of diarrhea has been a m a t t e r of common knowledge for m a n y years. The apple and banana have been tried and found to have favorable results and each has its advocates. 2 I n 1949 Smith and Fischer a reported the use of earob flour taken from the f r u i t of the earob tree, a leguminous plant which is native to the shores of the Mediterranean. This f r u i t (variously called St. John's bean, locust bean, Ceratonia siliqua) is a bean-shaped pod about 12 to 20 era. long by 2 era. wide. The pod contains a sweet pulp, rich in sugar (49 per cent) and low in protein (4 per cent) and very rich in lignin which is believed to be responsible for its unusual mechanical a n d detoxieating properties.
A
F r o m the General Hospital of F r e s n o County. l~resent a d d r e s s : Boston City Hospital, Boston, Mass. 182
CALIF.
Title purpose of the present study was to deternfine whether the favorable results in the management of the diarrheas with the use of carob flour (trade n a m e - - A r o b o n ) reported by Smith and Fischer a in 1949 and by Plowright 4 in 1951 could be confirmed by reviewing a larger number of cases. CLINICAL MATERIALS AND METHODS
The General Hospital of Fresno County located i n the center of the agricultural San Joaquin valley of California itas admitted to its pediatric service an average of 455 cases of acute infantile diarrhea annually for the past five years (1947 1951). Since the latter part of 1949 the pediatric service has been using earob flour (Arobon) as an adjunct in the dietetic treatment of diarrheas. Over a thousand eases of diarrhea have been tried on the carob flour regime. Of this number 300 cases were selected, and for control, 300 patients treated previously (1948) on a similar regime but without Arobon. Cases of equal or similar severity were selected from both groups. The ease histories,, doctor's orders, course in the hospital, and duration of treatment were scrutinized in order to p r o p e r l y classify the diarrheas. E x c e p t for the addition of Arobon to the dietetic regime, the treatment was similar in both groups. Because of the high costs of hospitalization, criterion for admission was generally as follows: (1) evidence of acidosis, (2) evidence of infection complicating the diarrhea, (3)
ABELLA:
INFANTILE
DIARRHEA
moderate to marked dehydration, (4) persistent v o m i t i n g accompanying diarrhea, and (5) failure to respond to treatnlent in clinic or outpatient department. F o r convenient evaluation the severity of the patient on admission was classified as follows: (1) Mild--diarrhea with little or no dehydration with carbon dioxide combining power over 35 vol. per cent. (2) Moderate--diarrhea usually accompanied by fever, moderate dehydration, and with carbon dioxide combining power of from 25 to 35 vol. per cent. (3) S e v e r e - diarrhea with extreme or marked dehydration, with carbon dioxide combining power below 25 vol. per cent, in moribund state or in extremis. Of the 600 cases reviewed, 44 per cent fell under the classification of " m i l d " diarrhea, 34 per cent were of "moderate" severity, and 22 per cent were in the "severe" group. Although the carbon dioxide combining power is one of the few objective measurements of the severity of the illness, it was taken in only a small group (6 per cent), perhaps because of the fact that there were not enough trained personnel to handle this laboratory procedure and so only the most necessary ones were taken. Frequently, however, t h e severity index could be welI defined clinically, i.e., the amount of acidosis is usually proportional to the amount of dehydration. In all eases studied it was routine procedure to have stool cultures daily for at least three days after admission. F o r those that were positive for Shigetla d*ysenteriae or of the Salmonella group, three negative stool cultures were reported before the patients were discharged. The ~ s u a ] admitting
AND
CAROB
FLOUR
183
laboratory studies, as a complete blood count and urinalysis, were done. P~an of Treatment.--The following is the regime used, the details modified according to the clinical symptoms, the duration, severity, and the objective laboratory findings: I. Period of Fasting: I t is usual to withhold all formula and oral medications for at least twelve hours, except in the mild eases without nausea or vonfiting and where hunger is evident. I f the child has not been vomiting, Ringer's-lactate or H a r t m a n n ' s solution is given every hour in amounts of 1 ounce and gradually increased by ~fie ounce until 3 to 4 ounces are tolerated. II. Feeding Plan: Guided by the patient's demonstration of tolerance to oral feedings, the earob flour, (Areben) preparation is then given (in the proportion of one-half of 10 per cent Arobon with one-half boiled skimmed milk) :in amounts according to the child's age. A f t e r the first formed stools, Arobon is then diluted with equal amounts of the "going-home formula," that is, one-half of 10 per cent Arobon and one-half of a 1:2 formula of evaporated milk. Then if the stools continue to be of satisfactory consistency, number, and volume, a straight "going-home formula" is finally givenP III. Parenteral Fluid Therapy: As soon as possible fluids are given either intravenously or by hypodermoelysis depending upon the amount of de* A 10 p e r c e n t s o l u t i o n A r o b o n i s p r e p a r e d b y a d d i n g 12 t a b l e s p o o n s f u l t o 32 o u n c e s o f water. Measure out Arobon into a dry pan a n d s t i r c o n s t a n t l y w h i l e p o u r i n g 10 o u n c e s o f cool sterile water (boiled previously f o r 10 minutes) onto the Arobon. The remaining amount of sterile water (22 ounces) is brought to a boil, the Arobon solution added t o it, a n d i t i s a g a i n b r o u g h t to a boil. As soon as the boiling point is reached, remove t h e f o r m u l a f r o m t h e fire, a l l o w i n g i t t o c o o l before pouring into the bottles.
184
THE
O0
O0
JOURNAL
OF
PEDIATRICS
T--I~
0
O0
E-i
,-4
~
o6
o~
~ ~.~ e ~
~.
"!.
d
"~
~o~,,~.~
I~
~"
o~ ~ I_
~
~
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.,z:~ . : . ~ ~
~
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~
~
~o
~ r ~ : ~ ~: ~ ~:,-~ ~:,.~ ~ ' 4
~ ~
~ ,, ,~
~|
o~
. ~
o:~i
i ,~ 441
ABELLA:
INFANTILE
185
D I A R R H E A AND CAROB F L O U R
hydration, a c i d o s i s, or circulatory shock. The choice of fluids also depends to a great extent on the clinical picture. As soon as the dehydration and acidosis are corrected and when oral feedings are tolerated, p a r e n t e r a l fluids are discontinued in f a v o r of the oral route.
Practically the same regimen was followed in the control group of 300 cases reviewed (comprising the period f r o m J a n u a r y to December, 1948,, before the use of Arobon was instituted in the dietetic t h e r a p y ) , except for the fact t h a t in the feeding plan as soon as the infant's tolerance to oral feed-
9O 80 70
..y-
~60
g
5o
~4o
Ill
~30
10
3an,Feb, Mar, Apt, May, June July Au~Sept. Oc% Nov, Dec. Fig. 1 . - - S e a s o n a l incidence. 20
18 16 14
10 8 6 /+
b
0-1
2
4
5 M(~THS
6
7
8
9
~' AGE
I0
11
12 13over
Fig. 2.--Age incidence.
IV: Chemotherapy: W h e n the clinical picture or the results of the stool cultures and other laboratory studies indicate, antibiotics alone or in combination are used to control the infection.
ing was evident, the formula was changed f r o m Ringer's-lactate solution to boiled skimmed milk. This f o r m u l a was kept up until stools became formed and the strength of the milk was g r a d u a l l y increased until the
]$6
child was mula."
THE JOURNAL OF PEDIATRICS
on the
"going-home for-
RESULTS
Table I is a s u m m a r y of the data collected f r o m the two groups of cases. The data u n d e r subgroup A in this table shows quite a comparable course in both the Arobon and non-Arobon groups. There w a s 4.79 average n u m b e r of days p r i o r to admission in the Arobon group as compared to 5.41 days in the non-Arobon group. The Arobon group had 9.30 average number of stools p r i o r to admission comparable to 7.45 average of the nonArobon group. The percentage with bloody stools on admission together with the percentage of those with p a r e n t e r a l complications are still within the normal limits of deviation. The data u n d e r Results show the differences in the results of the two groups. The Arobon group shows that formed stools are observed a f t e r an average of 1.16 days as compared to 6.08 days in the group without Arobon. I t took only an average of 5.97 days before the "going-home f o r m u l a " was tolerated in the Arobon group compared to 9.18 days in the nonArobon group. Patients t r e a t e d without Arobon stayed an average of 3.33 days longer in the hospital and had 6 per cent more readmissions. D u r i n g their hospital stay the average weight gain of those on Arobon was 14 ounces compared to 9.87 ounces a v e r a g e weight gain of those treated without Arobon. A definite seasonal incidence was noted (see Fig. 1). The lowest number of diarrhea admissions were during the months of F e b r u a r y , March, and April. A gradual increase occurred d u r i n g the summer, and the peak was
reached during the month of November. A n a b r u p t drop is observed during the cold months of December and January. Significantly, this seasonal incidence coincides with the seasonal migration of large groups of m i g r a n t laborers who work the vineyards and pick the cotton fields. P e r h a p s because of their economic handicap, o r d i n a r y s a n i t a r y conveniences and precautions are forgotten and p r o p e r care of their infants and children is wanting. I t is f r o m these workers in the r u r a l areas that the m a i n body of our patients comes. The incidence of infantile diarrheas according to age in both the Arobon and non-Arobon groups is shown in Fig. 2. There is a comparable age incidence in both groups. There is a higher incidence in infants u n d e r 6 months (70.5 p e r cent) t h a n in those over 6 months (20.5 per cent) of age. Only 9 per cent were children over one year. DISCUSSION
F u r t h e r review of the literature on carob flour reveals its use originally b y Ramos and Ronzalen 5 of Spain during the Spanish Civil War. E u r o p e a n pediatricians soon f o 11 o w e d suit. Megevand and Riederer 6 r e p o r t e d favorable results in studies in Switzerland. N e y r o u d ~ and his colleagues f r o m their studies in B e r n concluded that the use of carob flour represents a considerable progress in the dietetic t r e a t m e n t of infantile diarrhea. Vianello 8 writing f r o m the Pediatric Clinic of Bologna, I t a l y , confirmed its antidyspeptic properties. I t would seem t h a t earob flour (Arobon) is effective in r a p i d l y cutring down the n u m b e r and improving the consistency of the stools and thus
ABELLA:
INFANTILE DIARRHEA AND CAROB FLOUR
preventing further electrolyte loss and metabolic derangement. Diarrhea patients tolerate simple carbohydrates and proteins well but fats poorly. Arobon, with its content of 49 per cent soluble carbohydrates (sucrose and reducing sugars) and 4 per cent proteins with only 0.5 per cent fats, provides a food which with its rich lignin and pectin content acts not only to detoxieate and constipate but also provides an adequate amount of calories (75 calories per ounce by dr y weight). On the point of acceptability to the patient, it was noted that those below 12 months took the formula containing Arobon contentedly. Three patients over 12 months of age refused the chocolate-colored Arobon solution. No evidences of toxicity or side effects were noted in the 300 patients on Arobon. CONCLUSION
From the above studies, it would seem that the use of carob flour (Arobon) has been of considerable value as an adjunct in the dietetic therapy of infantile diarrheal disturbances, both in terms of shortening the p e r i o d of hospitalization and shortening the duration of the disease. This does not, however, lessen the paramount role of the administration of fluids and electrolytes in the treatment of diarrheas. SUMMARY
1. A study is presented of 600 cases of acute infantile diarrhea admitted to the pediatric' service of the General
187
IIospital of Fresno County. Three hundred of these cases were selected from those treated witlh earob flour (Arobon) as an adjun6t in the dietetic therapy, while the other 300 cases were those patients treated without Arobon. 2. In a tabulated comparison the Arobon and non-Arobon groups present a similar picture. The results show significant statistical differences. 3. As an adjunct in the dietetic therapy of acute infantile diarrhea, carob flour (Arobon) is of considerable value in hastening cure and recovery. REFERENCES 1. From studies made by the Bureau of Maternal and Child Health, Division of Prev e n t i v e Medical Services: " I n f a n t Mort a l i t y in California, 1920-]945," California Health 5: 6, 9-30, ]947. 2. Fries, J. tL, Chiara, N. J., and Waldron, tg. J.: D e h y d r a t e d Banana in Dietetic :Management of Diarrheas of Infancy, J. PEDIAT. 37: 529~ 1950. 3. Smith, A. E., and Fischer, C. C." The Use of Carob Flour in the T r e a t m e n t of Diarrhea in I n f a n t s and Children, J. PEDIAT. 35: 422, 1949. 4. Plowright, T. I~.: The Use of Carob Flour in a Controlled Series of I n f a n t Diarrhea, J. PEDIAT. 39: 16, 1951. 5. Ramos, R., and Rozalen, 3/[.: U n Nuevo Alimento-Medlcamento: La t t a r i n a de Algarroba, Rev. espan, farIn, y terap. 21: 1339, 1941. 6. 3/[egevand, J., and Riederer, V. de" Un Nouvelle Therapeutique pour les Troubles Digestifs Graves des Nourissous (Dyspex)j Rev. m6d. de la Suisse l~om. 61: 330, 1941. 7. Neyroud~ 3/I.: Carob Flour, a N e w Antidiarrheic Medicine, Ann. paediat. 166: 113, 1946. 8. Vianello, A.: Carob Flour and I t s Antidyspeptic Properties, L a t t a n t e 18: 282 (May) 1947. 9. Albritton, E. C.: To E s t i m a t e ~ P for the Difference Between Two Means, Exper. Design & Judge. of Evid. 1: 2], 1946.