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Treatment of epidemic diarrheas and dysenteries in infants and young children
T R E A T M E N T OF E P I D E M I C D I A R R H E A S AND D Y S E N T E R I E S IN INFANTS AND YOUNG CHILDREN COMPARATIVE
STUDY
OF DIFFERENT THEIR RESULTS
TREATMENTS
AND
KURT GLASER, M.D., aND JAMES W . BRUCE, ]~{.D. LOUISVILLE, I~Y.
R R H E A S and dysenteries in newborn infants, infants, and D I Ayoung children are not only the cause of long ailment and hospitalization, but also of many deaths every year. Table IA, IB, and IC show the importance of the condition from the public health aspect. The majority of cases are treated by practicing physicians and in clinics, and only the more severe cases are referred'to hospita]s. We wish to discuss certain changes in our treatment which have decreased the morbidity and mortality and considerably simplified tile management of the case in homes with untrained nursing staff. Tables IIA and I I B show the improvement of the results during the last years. We have divided our patients into two groups, those with diarrheas and those with dysenteries. In the first group we placed all patients with cases classified as nutritional diarrhea and those whose cases were caused by parenteral infection. The second group contains all patients with "specific" diarrhea caused by organisms belonging to the dysentery group. Except for the isolation technique observed in the dysentery form and' the different selection of sulfonamides, we have applied the same method of treatment in both conditions. TREATMENT
With the irritative state of the intestines, rest has to be provided. A period of starvation of twelve hours has been found satisfactory and has been practiced on all patients. During this time, the patients did not receive any food. Water and medication were given as needed. Dehydration is the most dreaded complication of diarrhea. Greatest attention was given to the prevention and treatment of this condition. The oral and intravenous ways were used practically exclusively. Our patients received plain, sterile water from the time of admission. By cup or bottle, water was offered at fifteen- to thirty-minute intervals, and the child encouraged to drink even if resistance was offered. In From the Pediatric Department of the Louisville General Hospital.
53
THE J O U R N A L OF PEDIATRICS
54
IA
TABLE TOTAL
DYSENTERY
CASES
(ALL
FORIKS) I)vEPOgTED ~" IN THE STATE 2~UGUS% AND ~EPTEMBER~ 1938 TO 1942
JULY~ yEAR
AUGUST
JULY
] 938 1939 1940 1941 1942
107 ]14 9 241 20
OF
SEPTEMBE~
69 82 55 80 24
41 46 23 45 12
I(ENTUCI~f
]TOTAL
FOg
t t
396 348 ~4-~ ~ 470 108
IN
YEAR
*Cases r e p o r t e d to D i v i s i o n of C o m m u n i c a b l e D i s e a s e s , K e n t u c k y Skate D e p a r t m e n t
of I~tealth.
IB
TABLE
DEATHS FI~O]K DIARRHEA AND DYSENTERY IN TIIE STATE OF KENTUCKY IN JULY~ 2~UGUSTt AND SEPTE~[BEI~t 19~0~ 1941~ AND 1942 ~ DIARRI-IEA YEAR
1940 1941 1942
JULY
])Y SENTERY
AUGUST
44 164 121
SEPI~EMBEg
91 161 83
J 14 148 88
JULY
AUGUST
14 58 31
31 43 30
SEPTEMBER
16 53 23
"19t2 is p r e l i m i n a r y only. .[(]
TABLE DEATHS
~ROIV[ DIAI~RHEA
AND
DYSENTERy
IN ~EN'I'UCKY
AND
TIIE UNITED
STATES~
1937 to 1942 ~ YEAR
K~.:NTUCKY DIARgIIEA
UNITED STATES
DIAI~gIIEA DYSENTERY 18,508 2~933 !5,128 2,537 ]3,537 2,~60 Data not available D a t a n o t available
DYSENTERY
1938 1196 1939 792 ]940 578 1941 827 1942 496 '1942 is preliminary only.
207 205 112 251 133
TABLE IIA
YEAR
T O T A L NUM:BER OF PATIENTS
t938 1939 1940 1941 1942
90 51 57 65 58
DEATII P~ATE
DEATHS
(%)
36 9 16 ]0 6
37.5 ]7.6 28.0 15,1 ] 0.34 TABLE
CORRECTED
YEAg
1940 1941 1942
STATISTICS
WITH ELIIKINA'I~ION I:[0URS 0g SOONER
TOTAL NUIffEEF~ OF PATIENTS
57 65 58
DEATHS
11 2
0
LONGEST HOSPITALIZATION TI~E O F DECEASED PATIENT
HOSPITALIZATION AT TIME 0F DEATH
0)AYS)
(DAYS) 64.0 23.0 30.0 3.0 1.33
12.1 ].2.1 i0.0 0.69 0.66
IIB OF ALL PATIENTS AFTER ~DIKISSION
DEATI-I RATE
(%)
]9.3 3.07 0
WlIo
DIED
HOSPITALIZATION AT TIME OF DEATH
(DAYS) I5.0 2.5 0
THIgTY-r.PWO
LONGEST HOSPITALIZATION AT TIME OF DEATH
(DAYS) 30 o
0
GLASER AND BRUCE:
EPIDEMIC DIARRHEAS AND DYSENTERIES
55
TABLE IIIA THE USE OF SULI~0NAI~IDES IN OUR SERIES DISEASE
P l e x n e r ' s dysentery
total Sonne d y g e n t e r y
I~iEDICATION
NUNfBEF~ ON CASES
Sulfathiazole Sulfaguanidine No s u l f o n a m i d e Sulfathiazole Sulfaguanidine No s u l f o n a m i d e
total N e g a t i v e l a b o r a t o r y report S u l f a t h i a z o l e Sulfaguanidine No s u l f o a a m l d e Total No l a b o r a t o r y r e p o r t found S u l f a t h i a z o l e Sulfaguanidino 011 records No s u l f o n a m i d e Total Morgani dysentery Grand total
AVEIZAGE DAYS OF HOSPITALIZATION
15 15 9~ 3 2 0 12' 3 9 24 9f ] 4+* 19
7 ~0
16.6 9.0 6.5 8.55 5.0 14.75
58
*One p a t i e n t died before t r e a t m e n t could be s t a r t e d ( t w e n t y h o u r s ) ; one p a t i e n t left the h o s p i t a l in less t h a n t w e n t y - f o u r h o u r s a g a i n s t advice. t T w o p a t i e n t s died before t r e a t m e n t could be s t a r t e d effectively. SThree p a t i e n t s died before t r e a t m e n t could be s t a r t e d effectively. T A B L E IIIB T H E U S E OF SULFONAMIDES
IN O u ~
SERIES
S~lfathiazole Gdve~, to Thdrty-Two Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y PoMtive on a d m i s s i o n Flexner Sonne Morg'ani No r e p o r t found on record Total
12 5 3 ]. 11 "~ 32.
S~d]'aguanidine Given to Ten Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y P o s i t i v e on a d m i s s i o n Flexner Sonne No r e p o r t f o u n d on record Total
3 4 2 1 10I
No Snlfonam~de Given to S~xteen Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y No r e p o r t s f o u n d on record Total
9 75 16
*Three p a t i e n t s died before stool specimen coul.d be obtained. The case of one p a t i e n t wets reported " p o s i t i v e " on d i s c h a r g e ; he left the h o s p i t a l a g a i n s t advice. t a l l cases were reported " n e g a t i v e " on discharge. SThree c a s e s died before stool specimen could be obtained,
56
T H E J O U R N A L OF PEDIATRICS
cases of advanced dehydration or acidosis, in a.ddition to the oral route, intravenous fluid was given. B y continuous drip through a fixed ankle vein cannula, a steady flow of physiologic salt solution, 5 per cent glucose in sterile water, or one of the two t I a r t m a n ' s ( I t a r t m a n n ' s ) solutions, was given for the first thirty-six hours. After hydration has improved, we have found that. blood transfusions are of greatest value to increase the resistance of the ehiId and improve his general condition. In some cases where hemoconcentration was too high, plasma has been given. Sulfathiazole and sulfaguanidine have been used extensively in our series of patients. W e have tried to treat: the nonspeeifie type of diarrhea with sulfathiazole and the specific diarrhea with sulfaguanidine. Due to delayed diagnosis, however, we ha~'e treated some speeifie types with sulfathiazole. Tables I I I A and I I I B show our resuits with these drugs. Bismuth and paregoric have been used only in extreme treatmentresistant eases. In one patient, polyvalent dysentery antiserum has been used with striking result. Tile system of feeding and its administration has been changed radically in our institution during the past years. I t also differs from ' the routine used in other hospitals and b y most practicing physicians. We believe that our method saves valuable time for the physician as well as for the nursing staff of hospitals and eertainly simplifies the care at private homes by untrained personnel. It is customary to offer and give only very small amounts of milk per feeding,-measured exactly and with careful supervision, and to increase this amount very slowly and raider very strict regulation. We have abandoned this method entirely and, as shown in the tables, have had better results than in previous years. Beginning twelve hours after admission to the ward, we have offered full bottles to our infants and given them as much as they will take. We have neither limited the amount nor forced the intake. The orders read : ' 'Buttermilk as tolerated," or "Skimmed boiled milk ad libitmn." Tables IVA and IVB show the very large amount of intake in the two age groups selected. The conclusions from these tables are as follows : 1. That the children have taken very large amounts of milk per feeding. 2. That they have regulated their intake according to their appetite without harm to the progress of their recovery. 3. That where too large amounts were offered, the child has ]imited the intake according to appetite. 4. That the improvement made rapid progress, and recovery occurred before the average hospitalization time of the patients treated by other methods two or more years ago.
GLASER AND BRUCE:
EPIDESIIC DIARRI~EA~ ANI) DYSENTERIFS
57
Fol]owing are some of the advantages of this form of diet: 1. The caloric value of the forms of milk to which diarrhea patients have to be limited is far below the value of whole milk or ordinary milk formulas. Buttermilk, skimmed boiled milk, and protein milk average from 10 to 12 calories per ounce. Breast milk and customary milk formulas rate about 20 calories per ounee. The caloric demand of a weakened undernourished child is certainly higher than the one of a healthy child. We believe, therefore, that the time of complete recovet)~ can be shortened considerably. Table V shows the decrease of hospitalization time during the past years. It has to be remarked that other factors besides the patient's medical condition influence the discharge time considerably. The soeial background, the use of a convalescent home, the overcrowding of our hospital, and the cooperation of a sociM service department are of decided importance. The question arises: Why not order a certain amount per feeding according to eMorie requirements? Our charts have shown, since we are dealing with sick children and low calorie food, that the calculated amounts will be very high, and that the nurse will be inclined to force the ordered amount. Especially in private homes, the mother will always be very concerned whether or not the baby has taken the "whole formula." The foreing of intake would, however, be not only of no value, but also very farmful to most patients. 2. The treatment of the hospital patient is greatly simplified by this method. The order written on the first day holds good for as many days as the physician wants to continue the same form of milk, irrespective of the amount. Comparing our orders to the attendant with these specifying the exact amount of milk, with the indications for time of changes daily or half daily, we can readily see the advantage of simplieity and clearness. 3. A still greater advantage of this liberal method of feeding is the treatment of the patient with diarrhea in private practice at the home of the patient with untrained and often not understanding nursing care. It is very difficult to instruct mothers coming from the less educated part of the population to measure feedings exactly. It is eertMnly next to impossible, to enforee limitation of feeding's when the child continues to cry and the mother feels that the cause is hunger. This has been a considerable burden to the doctor, and many unpleasant disputes originated from the " s t a r v i n g " of the patient. During the statistical test period in 1942, the following milk forms have been used: Buttermilk, skimmed boiled milk, and protein milk. In this we are using different methods from those used in previous years when whole boiled milk with or without sugar added and evaporated milk formulas were used. All those preparations contain a higher amount of dextrose and have a slight laxative effect (Table VI).
IN
]V[ONTIIS
AGE
.
1ST
[ 2ND
I 3RD
FIRST
I 4TH
DAY
~
I 5TH
I 6TH
]S~
I 2ND
I 3RD
SECOND
] 4TII
DAY
FEEDING (C,C.)
I 5TH
I 6TH
]S:P [ 2ND
I 3RD
TIIIRD
.
6 1.
120 . .
120
120 90 120 120 200 180
120 150 120 75 100 180 120 12,0
60 120 120 120 50 180 120 __
180 120 120
1;; 180 12:0 123
60 120 120 120
loo 183 120 120
180 120 240 120 100
180 120 150
183 120 240 120
183 120 150
183 180 120 90 100 180 120 150
180 150 240 105 100 180 120 150 120 150
150 GO 240
120 150
130 120
150 120 240 120 200 180 120 150
150 120 240 120 200 180 120 150
60
165 60
150 60
180 60
150 60
180 60
183 60
60 60
180 60
180 60
183 60
180 90
183 90
T w o P a t i e n t s [or W h o ~ n t h e Order W a s Specified (180 c.c. and 90 c.c. R e s p e e t i v e l y ) f
120 90 120 120 100 180
*Note the large amount of intake beginning the first clay. tNote the intake regulation by the child according to his appetite.
J.H. D. ~ .
M.D. M.E.G. D.A. M. A. A. D. P. J. R. M. J. M. R.
])~ Co
90 90
150 120 200 120 200 180 120 150
E i g h t P a t i e n t s f o r W h o m the Order 2~ea,d " A s T o l e r a t e d " or " A d L i b i t u m " ; B u t t e r m i l k or S k i m m e d Boiled M i l k the F i r s t T w e l v e H o u r s the P a t i e n t s l~eeeived Only " S t e r i l e W a t e r "
INITI)~LS
TABLE I V A TEN OF OUR PATIENTS IN THE AGE GI~OUP OF TtIE FIRST ONE-~IALF YEAI~ OF LIFE
I 5TH
I 6rH
180 90
180 60 200 120 100 180 120 150
180 90
18J 60 200 120 200 183 120 150
180 90
180 120 --_180 120 150
W a s Given; D u r i n g
14TH
DAY
5,284
o
o
~j
~_]~
CYr OO
] 2NB
FIRST DAY~ I 3RD ] 4TI-I ] 5TIt ] 6TIt
SECOND DAY 1ST ] 2ND ] 3RD ] 4 T H I 5TH ] 6TtI
FE~DI~G (C.C.) 1ST
THIRD DAY
7 9.
C.T. B. 5. D .
183 . .
9O
17o
~o
200 35 240 183 120 240 120 12,0
200 60 240 180 105 240 120 180 3; 240 183 120 240 120 120 240 120 80
180
--
30 90 240 180 120 240 120 120
200 90 240 180 120 240 120 120
t50 90 240 183 170 240 120 120
250 90 180 180 180 240 120 150 90 240 180 120 240 120 150 180 180 240 120 180
__
200 90 240 180 120 240 120 120
200 90 240 180 190 240 120 120
180
183 45
180 60
189 60
180 60
120 60
120 60
180 90
180 30
183 90
180 30
180 69
180 60
T w o P a t i e n t s f o r W h o m the Order W a s Specified (180 c.e. and 90 c.e. Respeetively)$
120 90
90
--
*Note t h e l a r g e a m o u n t of i n t a k e b e g i n n i n g the first day. t P a t i e n t A. T. took on th e second a n d t h i r d d a y s two a d d i t i o n a l fe e di ngs each (150 a nd 120 e.c., 150 a nd 180 c.c.) SNore the i n t a k e r e g u l a t i o n by the child a c c ordi ng to his appetite.
.
11 8 7 10 8 11 6 8
180 90
200 120 240 180 190 200 120 150
180 60
240 180 190 200 120 150 180 60
17; 240 180 190 200 120 150
12o
240
180 90
240 180 12,0 240 120 150
W a s Given; D u r
I 2ND I 3RD ] 4TIcI ] 5T~ ] 6TH--
P a t i e n t s f o r W h o m the Order l~ead " A s T o l e r a t e d " or " A d L i b i t u m ' ~ ; Buttermilt~ or S k i m m e d B o i l e d M i l k the 7First T w e l v e Hmors the P a t i e n t s Received Only " S t e r i l e W a t e r "
D. V. J.S. P.G. E. E. C. J. L. ~L W.D. M. F. W. A. T . t
Eight
INITIALS
AGE IN I~IONTIcIS 1ST
TABLE I V B TEN OF OUR PATIENTS IN TI-IE AGE ~ROUP OF THE SECOND ONE-HALF YEAI:~ OF LIFE
Z
>
c~ ~
>
60
THE JOURNAL OF PEDIATRICS TABLE fl~.VEI%AGE
~UIVIBEI~ OF DAYS ]:IOSPITAL IN
YEAP~
1938 1939 1940 1941 1942
V
OF HOSPITALIZtITION OF ~ : IIVfPROVED ~ t OR ~ ~ WELL
PATIENTS WHO ' ' CONDITION
DIARRHEAS 15.0 20.5 15.6 9.0 ]1.4
LEFT
THE
DYSENTERIES 14.6 18.6 15.7 6.8 11.3
TABLE V I ]?OF~IVs OI~1 MILK GIVEN TO 0U1% PATIENTS IN THE MONTHS OF JULY, AUGUST, AND SEPTE:~s ER~ ]942. NU1V[BEI%OF PATIENTS 41 7 1 1
FOK1VfOF 1VIILK Bnttermilk Skimmed boiled milk Protein milk Whole boiled milk 6 Evaporated milk formulas 4 ~Tothing (Died before feeding time) The above table is made to show the forms of milk which were ordered on admission. Only patients whose history showed that buttermilk was not well tolerated received skimmed boiled milk or protein milk. Evaporated milk formula or whole boiled milk was giveu only to those patients who were admitted primarily for another condition or under another diagnosis. In some cases the formula was changed during the course of the hospitalization if we felt that the child was not responding to the treatment the way he should.
Upon cessation of the diarrhea, which we considered established after the number, consistency, color, and odor of the stools had returned to normal for from two to four days, a gradual change was made to a normal formula. We accomplished this by replacing fractions of the average amount of buttermilk taken and by increasing those fractions in from twenty-four- to forty-eight-hour intervals until the normal formula was reached. SUMMARY AND CONCLUSION ]. D i a r r h e a s a n d d y s e n t e r i e s h a v e been classified in t h i s p a p e r in two g r o u p s : the non-specific an d t h e specific forms. 2. C o n s i d e r e d are th e p a t i e n t s t r e a t e d in t h e L o u i s v i l l e G e n e r a l H o s p i t a l d u r i n g the m o n t h s of J u l y , A u g u s t , a n d S e p t e m b e r f r o m 1938 to ]942, w i t h special a t t e n t i o n to t h e p a t i e n t s of ]942. 3. A n e w m e t h o d of f e e d i n g has been p u t on t r i a l a n d w a s f o u n d successful d u r i n g t h e last two years, as p r o v e d b y t h e f o l l o w i n g f a c t s : (a) T h e a v e r a g e h o s p i t a l i z a t i o n t i m e has d e c r e a s e d ( T a b l e V ) . (b) T h e t o t a l n u m b e r of d e a t h s has d e c r e a s e d ( T a M e I I ) . (c) T h e d e a t h r a t e h a s d e c r e a s e d ( T a b l e I I ) . (d) T h e a v e r a g e a n d i n d i v i d u a l h o s p i t a l i z a t i o n t i m e of t h e p a t i e n t s who d i e d in the test m o n t h s in 1942 was so s h o r t as to j u s t i f y these p a t i e n t s b e i n g c o n s i d e r e d m o r i b u n d on ad m i ssi o n as done i n T a M e I I B, s h o w i n g a d e a t h r a t e of zero i n c l u d e d in o u r statistics.
G L A S E R AND B R U C E :
EPIDEMIC D I A R R H E A S AND D Y S E N T E R I E S
61
4. The new method consists in the administration of unlimited amount of feedings, selected especially for the diarrhea ease. 5. The main principles of our treatment are outlined below: (a) Starvation period (twelve hours). (b) Oral and intravenous hydration and combat of acidosis. (e) Feeding of buttermilk, skimmed boiled milk, or protein milk in from three to four hourly intervals, the amount regulated entirely by the appetite of the patient. (d) Sulfathiaz01e and sulfaguanidine. (e) Plasma and blood transfusions. (f) Specific antiserum therapy. (g) Bismuth and paregoric only in treatment of the resistant patient.
STUDY
OF DIFFERENT THEIR RESULTS
TREATMENTS
AND
KURT GLASER, M.D., aND JAMES W . BRUCE, ]~{.D. LOUISVILLE, I~Y.
R R H E A S and dysenteries in newborn infants, infants, and D I Ayoung children are not only the cause of long ailment and hospitalization, but also of many deaths every year. Table IA, IB, and IC show the importance of the condition from the public health aspect. The majority of cases are treated by practicing physicians and in clinics, and only the more severe cases are referred'to hospita]s. We wish to discuss certain changes in our treatment which have decreased the morbidity and mortality and considerably simplified tile management of the case in homes with untrained nursing staff. Tables IIA and I I B show the improvement of the results during the last years. We have divided our patients into two groups, those with diarrheas and those with dysenteries. In the first group we placed all patients with cases classified as nutritional diarrhea and those whose cases were caused by parenteral infection. The second group contains all patients with "specific" diarrhea caused by organisms belonging to the dysentery group. Except for the isolation technique observed in the dysentery form and' the different selection of sulfonamides, we have applied the same method of treatment in both conditions. TREATMENT
With the irritative state of the intestines, rest has to be provided. A period of starvation of twelve hours has been found satisfactory and has been practiced on all patients. During this time, the patients did not receive any food. Water and medication were given as needed. Dehydration is the most dreaded complication of diarrhea. Greatest attention was given to the prevention and treatment of this condition. The oral and intravenous ways were used practically exclusively. Our patients received plain, sterile water from the time of admission. By cup or bottle, water was offered at fifteen- to thirty-minute intervals, and the child encouraged to drink even if resistance was offered. In From the Pediatric Department of the Louisville General Hospital.
53
THE J O U R N A L OF PEDIATRICS
54
IA
TABLE TOTAL
DYSENTERY
CASES
(ALL
FORIKS) I)vEPOgTED ~" IN THE STATE 2~UGUS% AND ~EPTEMBER~ 1938 TO 1942
JULY~ yEAR
AUGUST
JULY
] 938 1939 1940 1941 1942
107 ]14 9 241 20
OF
SEPTEMBE~
69 82 55 80 24
41 46 23 45 12
I(ENTUCI~f
]TOTAL
FOg
t t
396 348 ~4-~ ~ 470 108
IN
YEAR
*Cases r e p o r t e d to D i v i s i o n of C o m m u n i c a b l e D i s e a s e s , K e n t u c k y Skate D e p a r t m e n t
of I~tealth.
IB
TABLE
DEATHS FI~O]K DIARRHEA AND DYSENTERY IN TIIE STATE OF KENTUCKY IN JULY~ 2~UGUSTt AND SEPTE~[BEI~t 19~0~ 1941~ AND 1942 ~ DIARRI-IEA YEAR
1940 1941 1942
JULY
])Y SENTERY
AUGUST
44 164 121
SEPI~EMBEg
91 161 83
J 14 148 88
JULY
AUGUST
14 58 31
31 43 30
SEPTEMBER
16 53 23
"19t2 is p r e l i m i n a r y only. .[(]
TABLE DEATHS
~ROIV[ DIAI~RHEA
AND
DYSENTERy
IN ~EN'I'UCKY
AND
TIIE UNITED
STATES~
1937 to 1942 ~ YEAR
K~.:NTUCKY DIARgIIEA
UNITED STATES
DIAI~gIIEA DYSENTERY 18,508 2~933 !5,128 2,537 ]3,537 2,~60 Data not available D a t a n o t available
DYSENTERY
1938 1196 1939 792 ]940 578 1941 827 1942 496 '1942 is preliminary only.
207 205 112 251 133
TABLE IIA
YEAR
T O T A L NUM:BER OF PATIENTS
t938 1939 1940 1941 1942
90 51 57 65 58
DEATII P~ATE
DEATHS
(%)
36 9 16 ]0 6
37.5 ]7.6 28.0 15,1 ] 0.34 TABLE
CORRECTED
YEAg
1940 1941 1942
STATISTICS
WITH ELIIKINA'I~ION I:[0URS 0g SOONER
TOTAL NUIffEEF~ OF PATIENTS
57 65 58
DEATHS
11 2
0
LONGEST HOSPITALIZATION TI~E O F DECEASED PATIENT
HOSPITALIZATION AT TIME 0F DEATH
0)AYS)
(DAYS) 64.0 23.0 30.0 3.0 1.33
12.1 ].2.1 i0.0 0.69 0.66
IIB OF ALL PATIENTS AFTER ~DIKISSION
DEATI-I RATE
(%)
]9.3 3.07 0
WlIo
DIED
HOSPITALIZATION AT TIME OF DEATH
(DAYS) I5.0 2.5 0
THIgTY-r.PWO
LONGEST HOSPITALIZATION AT TIME OF DEATH
(DAYS) 30 o
0
GLASER AND BRUCE:
EPIDEMIC DIARRHEAS AND DYSENTERIES
55
TABLE IIIA THE USE OF SULI~0NAI~IDES IN OUR SERIES DISEASE
P l e x n e r ' s dysentery
total Sonne d y g e n t e r y
I~iEDICATION
NUNfBEF~ ON CASES
Sulfathiazole Sulfaguanidine No s u l f o n a m i d e Sulfathiazole Sulfaguanidine No s u l f o n a m i d e
total N e g a t i v e l a b o r a t o r y report S u l f a t h i a z o l e Sulfaguanidine No s u l f o a a m l d e Total No l a b o r a t o r y r e p o r t found S u l f a t h i a z o l e Sulfaguanidino 011 records No s u l f o n a m i d e Total Morgani dysentery Grand total
AVEIZAGE DAYS OF HOSPITALIZATION
15 15 9~ 3 2 0 12' 3 9 24 9f ] 4+* 19
7 ~0
16.6 9.0 6.5 8.55 5.0 14.75
58
*One p a t i e n t died before t r e a t m e n t could be s t a r t e d ( t w e n t y h o u r s ) ; one p a t i e n t left the h o s p i t a l in less t h a n t w e n t y - f o u r h o u r s a g a i n s t advice. t T w o p a t i e n t s died before t r e a t m e n t could be s t a r t e d effectively. SThree p a t i e n t s died before t r e a t m e n t could be s t a r t e d effectively. T A B L E IIIB T H E U S E OF SULFONAMIDES
IN O u ~
SERIES
S~lfathiazole Gdve~, to Thdrty-Two Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y PoMtive on a d m i s s i o n Flexner Sonne Morg'ani No r e p o r t found on record Total
12 5 3 ]. 11 "~ 32.
S~d]'aguanidine Given to Ten Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y P o s i t i v e on a d m i s s i o n Flexner Sonne No r e p o r t f o u n d on record Total
3 4 2 1 10I
No Snlfonam~de Given to S~xteen Patients Stool r e p o r t s : N e g a t i v e for d y s e n t e r y No r e p o r t s f o u n d on record Total
9 75 16
*Three p a t i e n t s died before stool specimen coul.d be obtained. The case of one p a t i e n t wets reported " p o s i t i v e " on d i s c h a r g e ; he left the h o s p i t a l a g a i n s t advice. t a l l cases were reported " n e g a t i v e " on discharge. SThree c a s e s died before stool specimen could be obtained,
56
T H E J O U R N A L OF PEDIATRICS
cases of advanced dehydration or acidosis, in a.ddition to the oral route, intravenous fluid was given. B y continuous drip through a fixed ankle vein cannula, a steady flow of physiologic salt solution, 5 per cent glucose in sterile water, or one of the two t I a r t m a n ' s ( I t a r t m a n n ' s ) solutions, was given for the first thirty-six hours. After hydration has improved, we have found that. blood transfusions are of greatest value to increase the resistance of the ehiId and improve his general condition. In some cases where hemoconcentration was too high, plasma has been given. Sulfathiazole and sulfaguanidine have been used extensively in our series of patients. W e have tried to treat: the nonspeeifie type of diarrhea with sulfathiazole and the specific diarrhea with sulfaguanidine. Due to delayed diagnosis, however, we ha~'e treated some speeifie types with sulfathiazole. Tables I I I A and I I I B show our resuits with these drugs. Bismuth and paregoric have been used only in extreme treatmentresistant eases. In one patient, polyvalent dysentery antiserum has been used with striking result. Tile system of feeding and its administration has been changed radically in our institution during the past years. I t also differs from ' the routine used in other hospitals and b y most practicing physicians. We believe that our method saves valuable time for the physician as well as for the nursing staff of hospitals and eertainly simplifies the care at private homes by untrained personnel. It is customary to offer and give only very small amounts of milk per feeding,-measured exactly and with careful supervision, and to increase this amount very slowly and raider very strict regulation. We have abandoned this method entirely and, as shown in the tables, have had better results than in previous years. Beginning twelve hours after admission to the ward, we have offered full bottles to our infants and given them as much as they will take. We have neither limited the amount nor forced the intake. The orders read : ' 'Buttermilk as tolerated," or "Skimmed boiled milk ad libitmn." Tables IVA and IVB show the very large amount of intake in the two age groups selected. The conclusions from these tables are as follows : 1. That the children have taken very large amounts of milk per feeding. 2. That they have regulated their intake according to their appetite without harm to the progress of their recovery. 3. That where too large amounts were offered, the child has ]imited the intake according to appetite. 4. That the improvement made rapid progress, and recovery occurred before the average hospitalization time of the patients treated by other methods two or more years ago.
GLASER AND BRUCE:
EPIDESIIC DIARRI~EA~ ANI) DYSENTERIFS
57
Fol]owing are some of the advantages of this form of diet: 1. The caloric value of the forms of milk to which diarrhea patients have to be limited is far below the value of whole milk or ordinary milk formulas. Buttermilk, skimmed boiled milk, and protein milk average from 10 to 12 calories per ounce. Breast milk and customary milk formulas rate about 20 calories per ounee. The caloric demand of a weakened undernourished child is certainly higher than the one of a healthy child. We believe, therefore, that the time of complete recovet)~ can be shortened considerably. Table V shows the decrease of hospitalization time during the past years. It has to be remarked that other factors besides the patient's medical condition influence the discharge time considerably. The soeial background, the use of a convalescent home, the overcrowding of our hospital, and the cooperation of a sociM service department are of decided importance. The question arises: Why not order a certain amount per feeding according to eMorie requirements? Our charts have shown, since we are dealing with sick children and low calorie food, that the calculated amounts will be very high, and that the nurse will be inclined to force the ordered amount. Especially in private homes, the mother will always be very concerned whether or not the baby has taken the "whole formula." The foreing of intake would, however, be not only of no value, but also very farmful to most patients. 2. The treatment of the hospital patient is greatly simplified by this method. The order written on the first day holds good for as many days as the physician wants to continue the same form of milk, irrespective of the amount. Comparing our orders to the attendant with these specifying the exact amount of milk, with the indications for time of changes daily or half daily, we can readily see the advantage of simplieity and clearness. 3. A still greater advantage of this liberal method of feeding is the treatment of the patient with diarrhea in private practice at the home of the patient with untrained and often not understanding nursing care. It is very difficult to instruct mothers coming from the less educated part of the population to measure feedings exactly. It is eertMnly next to impossible, to enforee limitation of feeding's when the child continues to cry and the mother feels that the cause is hunger. This has been a considerable burden to the doctor, and many unpleasant disputes originated from the " s t a r v i n g " of the patient. During the statistical test period in 1942, the following milk forms have been used: Buttermilk, skimmed boiled milk, and protein milk. In this we are using different methods from those used in previous years when whole boiled milk with or without sugar added and evaporated milk formulas were used. All those preparations contain a higher amount of dextrose and have a slight laxative effect (Table VI).
IN
]V[ONTIIS
AGE
.
1ST
[ 2ND
I 3RD
FIRST
I 4TH
DAY
~
I 5TH
I 6TH
]S~
I 2ND
I 3RD
SECOND
] 4TII
DAY
FEEDING (C,C.)
I 5TH
I 6TH
]S:P [ 2ND
I 3RD
TIIIRD
.
6 1.
120 . .
120
120 90 120 120 200 180
120 150 120 75 100 180 120 12,0
60 120 120 120 50 180 120 __
180 120 120
1;; 180 12:0 123
60 120 120 120
loo 183 120 120
180 120 240 120 100
180 120 150
183 120 240 120
183 120 150
183 180 120 90 100 180 120 150
180 150 240 105 100 180 120 150 120 150
150 GO 240
120 150
130 120
150 120 240 120 200 180 120 150
150 120 240 120 200 180 120 150
60
165 60
150 60
180 60
150 60
180 60
183 60
60 60
180 60
180 60
183 60
180 90
183 90
T w o P a t i e n t s [or W h o ~ n t h e Order W a s Specified (180 c.c. and 90 c.c. R e s p e e t i v e l y ) f
120 90 120 120 100 180
*Note the large amount of intake beginning the first clay. tNote the intake regulation by the child according to his appetite.
J.H. D. ~ .
M.D. M.E.G. D.A. M. A. A. D. P. J. R. M. J. M. R.
])~ Co
90 90
150 120 200 120 200 180 120 150
E i g h t P a t i e n t s f o r W h o m the Order 2~ea,d " A s T o l e r a t e d " or " A d L i b i t u m " ; B u t t e r m i l k or S k i m m e d Boiled M i l k the F i r s t T w e l v e H o u r s the P a t i e n t s l~eeeived Only " S t e r i l e W a t e r "
INITI)~LS
TABLE I V A TEN OF OUR PATIENTS IN THE AGE GI~OUP OF TtIE FIRST ONE-~IALF YEAI~ OF LIFE
I 5TH
I 6rH
180 90
180 60 200 120 100 180 120 150
180 90
18J 60 200 120 200 183 120 150
180 90
180 120 --_180 120 150
W a s Given; D u r i n g
14TH
DAY
5,284
o
o
~j
~_]~
CYr OO
] 2NB
FIRST DAY~ I 3RD ] 4TI-I ] 5TIt ] 6TIt
SECOND DAY 1ST ] 2ND ] 3RD ] 4 T H I 5TH ] 6TtI
FE~DI~G (C.C.) 1ST
THIRD DAY
7 9.
C.T. B. 5. D .
183 . .
9O
17o
~o
200 35 240 183 120 240 120 12,0
200 60 240 180 105 240 120 180 3; 240 183 120 240 120 120 240 120 80
180
--
30 90 240 180 120 240 120 120
200 90 240 180 120 240 120 120
t50 90 240 183 170 240 120 120
250 90 180 180 180 240 120 150 90 240 180 120 240 120 150 180 180 240 120 180
__
200 90 240 180 120 240 120 120
200 90 240 180 190 240 120 120
180
183 45
180 60
189 60
180 60
120 60
120 60
180 90
180 30
183 90
180 30
180 69
180 60
T w o P a t i e n t s f o r W h o m the Order W a s Specified (180 c.e. and 90 c.e. Respeetively)$
120 90
90
--
*Note t h e l a r g e a m o u n t of i n t a k e b e g i n n i n g the first day. t P a t i e n t A. T. took on th e second a n d t h i r d d a y s two a d d i t i o n a l fe e di ngs each (150 a nd 120 e.c., 150 a nd 180 c.c.) SNore the i n t a k e r e g u l a t i o n by the child a c c ordi ng to his appetite.
.
11 8 7 10 8 11 6 8
180 90
200 120 240 180 190 200 120 150
180 60
240 180 190 200 120 150 180 60
17; 240 180 190 200 120 150
12o
240
180 90
240 180 12,0 240 120 150
W a s Given; D u r
I 2ND I 3RD ] 4TIcI ] 5T~ ] 6TH--
P a t i e n t s f o r W h o m the Order l~ead " A s T o l e r a t e d " or " A d L i b i t u m ' ~ ; Buttermilt~ or S k i m m e d B o i l e d M i l k the 7First T w e l v e Hmors the P a t i e n t s Received Only " S t e r i l e W a t e r "
D. V. J.S. P.G. E. E. C. J. L. ~L W.D. M. F. W. A. T . t
Eight
INITIALS
AGE IN I~IONTIcIS 1ST
TABLE I V B TEN OF OUR PATIENTS IN TI-IE AGE ~ROUP OF THE SECOND ONE-HALF YEAI:~ OF LIFE
Z
>
c~ ~
>
60
THE JOURNAL OF PEDIATRICS TABLE fl~.VEI%AGE
~UIVIBEI~ OF DAYS ]:IOSPITAL IN
YEAP~
1938 1939 1940 1941 1942
V
OF HOSPITALIZtITION OF ~ : IIVfPROVED ~ t OR ~ ~ WELL
PATIENTS WHO ' ' CONDITION
DIARRHEAS 15.0 20.5 15.6 9.0 ]1.4
LEFT
THE
DYSENTERIES 14.6 18.6 15.7 6.8 11.3
TABLE V I ]?OF~IVs OI~1 MILK GIVEN TO 0U1% PATIENTS IN THE MONTHS OF JULY, AUGUST, AND SEPTE:~s ER~ ]942. NU1V[BEI%OF PATIENTS 41 7 1 1
FOK1VfOF 1VIILK Bnttermilk Skimmed boiled milk Protein milk Whole boiled milk 6 Evaporated milk formulas 4 ~Tothing (Died before feeding time) The above table is made to show the forms of milk which were ordered on admission. Only patients whose history showed that buttermilk was not well tolerated received skimmed boiled milk or protein milk. Evaporated milk formula or whole boiled milk was giveu only to those patients who were admitted primarily for another condition or under another diagnosis. In some cases the formula was changed during the course of the hospitalization if we felt that the child was not responding to the treatment the way he should.
Upon cessation of the diarrhea, which we considered established after the number, consistency, color, and odor of the stools had returned to normal for from two to four days, a gradual change was made to a normal formula. We accomplished this by replacing fractions of the average amount of buttermilk taken and by increasing those fractions in from twenty-four- to forty-eight-hour intervals until the normal formula was reached. SUMMARY AND CONCLUSION ]. D i a r r h e a s a n d d y s e n t e r i e s h a v e been classified in t h i s p a p e r in two g r o u p s : the non-specific an d t h e specific forms. 2. C o n s i d e r e d are th e p a t i e n t s t r e a t e d in t h e L o u i s v i l l e G e n e r a l H o s p i t a l d u r i n g the m o n t h s of J u l y , A u g u s t , a n d S e p t e m b e r f r o m 1938 to ]942, w i t h special a t t e n t i o n to t h e p a t i e n t s of ]942. 3. A n e w m e t h o d of f e e d i n g has been p u t on t r i a l a n d w a s f o u n d successful d u r i n g t h e last two years, as p r o v e d b y t h e f o l l o w i n g f a c t s : (a) T h e a v e r a g e h o s p i t a l i z a t i o n t i m e has d e c r e a s e d ( T a b l e V ) . (b) T h e t o t a l n u m b e r of d e a t h s has d e c r e a s e d ( T a M e I I ) . (c) T h e d e a t h r a t e h a s d e c r e a s e d ( T a b l e I I ) . (d) T h e a v e r a g e a n d i n d i v i d u a l h o s p i t a l i z a t i o n t i m e of t h e p a t i e n t s who d i e d in the test m o n t h s in 1942 was so s h o r t as to j u s t i f y these p a t i e n t s b e i n g c o n s i d e r e d m o r i b u n d on ad m i ssi o n as done i n T a M e I I B, s h o w i n g a d e a t h r a t e of zero i n c l u d e d in o u r statistics.
G L A S E R AND B R U C E :
EPIDEMIC D I A R R H E A S AND D Y S E N T E R I E S
61
4. The new method consists in the administration of unlimited amount of feedings, selected especially for the diarrhea ease. 5. The main principles of our treatment are outlined below: (a) Starvation period (twelve hours). (b) Oral and intravenous hydration and combat of acidosis. (e) Feeding of buttermilk, skimmed boiled milk, or protein milk in from three to four hourly intervals, the amount regulated entirely by the appetite of the patient. (d) Sulfathiaz01e and sulfaguanidine. (e) Plasma and blood transfusions. (f) Specific antiserum therapy. (g) Bismuth and paregoric only in treatment of the resistant patient.