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Gastro-Enteritis in Infancy an Account of 286 Cases Treated in a General Paediatric Hospital by N

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Gastro-Enteritis in Infancy an Account of 286 Cases Treated in a General Paediatric Hospital by N Arch Dis Child: first published as 10.1136/adc.27.135.457 on 1 October 1952. Downloaded from GASTRO-ENTERITIS IN INFANCY AN ACCOUNT OF 286 CASES TREATED IN A GENERAL PAEDIATRIC HOSPITAL BY N. M. MANN, SHEILA ROSS and W. H. PATTERSON FromBooth HallHospital, Manchester (RECEIVED FOR PUBLICATION FEBRUARY 25, 1952) Gastro-enteritis in infancy still remains one of the In 1950, 37 babies under 1 year of age (2-4 per most challenging problems in paediatrics. In 1945 1,000 live births) died from this disease in deaths from diarrhoea and enteritis accounted for Manchester. The city's position relative to the 11 % of the total infant mortality (Martin, 1949). country as a whole and to certain other areas is The death rate has continued to fall, and in 1948 shown in the accompanying table (Brown, 1950). 2,304 infants under 1 year of age, or 2 * 88 per 1,000 live births, died from the disease in England and Death Rate from Diarrhoea and Wales (Registrar-General, 1950). This has led Enteritis in Infants under 2 Years per 1,000 Live Births Moncrieff (1950) to state: Protected by copyright. England ' The preventive service has to a large extent won and Wales .. .. 19 its fight against the scourge of infective diarrhoea as 126 county boroughs and great a national problem, although this is no excuse for towns, including London .. 22 allowing breast-feeding to decline still further or for 148 smaller towns, population slackening every effort to prevent outbreaks on a 25,000 to 50,000 1-6 small scale in institutions. The new antibiotics and a better understanding of the clinical management of London Administrative County 1 0 the infant with the " diarrhoea and vomiting" Manchester 3 0 syndrome may lower the death rate even further.' The object of this paper is to discuss the diagnosis The struggle against the disease began in 1894 and the management of the disease in a general when Dr. James Niven became Medical Officer of paediatric hospital in Manchester, with a brief Health. His predecessor, Mr. Leigh, had initiated historical introduction to the problems of the past. the conversion of midden-privies and cesspools to Gastro-enteritis in infancy is largely a social the pail closet system. For a time the health of the disease, and Cruickshank (1943) summed it up as population was much improved, but this policy had http://adc.bmj.com/ an infection of artificially fed infants living in the failed. The houses were frequently round courts bad and overcrowded housing of poor urban entered by a ginnel and the smaller streets were districts. often blocked at one end. The air was ' oppressive Historical and malodorous'. Urine trickled out from the The incidence of diarrhoeal diseases in this highly closet chambers, and foul liquid soaked into the industrial city has always been high. The mortality soil from the defective drains. 'The excreta were per 1,000 live births has usually exceeded that for collected in midden privies in the courts at the ends on September 25, 2021 by guest. England and Wales and at one period it was the outside the houses and in the narrow back passages. highest in the land. Thus, in the Public Health Often as many as six to eight houses were served by Report for 1903 is the rueful comment, 'Manchester one privy.' The conditions must have been well occupies the usual position relative to other towns'. nigh unendurable. In order to alleviate some of the At the turn of the century, the mean annual mortality evils the Council separated the dry from the wet rate for 10 years was 812 (38 31 per 1,000 live births) materials and the urine was collected in cesspools. compared with the total of 36,000 deaths (31 per Mr. Leigh estimates that ' had the contents of these 1,000 live births) for the country in 1898 (Hutchison, cesspools been collected in one place, they would 1940). have formed a lake 5 ft. deep and 16 times the area There has been a steady decline since except for a of St. Ann's Square ' (9 acres !). The subject was flare-up of the disease in 1911 and another brief and once more taken up and a movement was made small rise in 1947 towards the conversion of pails to water-closets, and 457 32 Arch Dis Child: first published as 10.1136/adc.27.135.457 on 1 October 1952. Downloaded from 458 ARCHIVES OF DISEASE IN CHILDHOOD the scheme was almost complete by 1914. This serious defect-the distance of removal was not change was probably the biggest single factor in specified. ' Manure might be removed to another reducing the mortality from summer diarrhoea depot a few yards off and a whole brood of flies (Walker, 1951). might be generated under the bye-laws.' An intensive investigation of the causation of When he retired in 1923 and wrote his History of summer diarrhoea was carried out from 1903 to Public Health Effort in Manchester Dr. Niven 1906. The Health Report for 1904 records an concluded that the improvement in the death rate investigation into the home conditions and infant from diarrhoea could be attributed to two causes. feeding of 111 fatal cases. The case notes provide a One was the gradual increase in health visiting staffs fascinating insight into the appalling social conditions and the instructions given at welfare centres, and the and the contemporary ignorance of domestic hygiene other was the speedy removal of horse manure to the and infant management. 'It was noticed that, on country. Despite this prolonged and tremendous the whole, the separation of districts according to effort, he regretted that his task was unfinished, and diarrhoeal death-rates marks also a social separation ' in no one thing do I regret that more than in and also a separation in regard to cleanliness.' regard to summer diarrhoea'. It was noted even then that breast-fed babies remained comparatively well and generally escaped Present Series diarrhoea all the year round. The present series of 286 cases covers a period of The report provided clear evidence of the direct two years, 1949 and 1950. They are those remain- spread of infection in many cases. Much could also ing out of 427 cases after an exhaustive scrutiny of be ascribed to contaminated milk. It was still their records by two experienced observers, with necessary to explain the autumnal rise when the recourse to an experienced paediatrician for greater part of the mortality occurred. adjudication in doubtfulcases. Protected by copyright. The relationship between the house fly and the We have reason to believe that it is still too autumnal epidemics of diarrhoea was proved by the common elsewhere to use the term ' gastro-enteritis ' setting of fly traps by reliable householders under the loosely in cases of diarrhoea and vomiting, and far supervision of the Ladies' Public Health Society. beyond that which we know to be the upper age The correspondence between the high fly counts and limit. the high weekly mortality from diarrhoea was Our cases do not include any of the specific startling. gastro-intestinal infections, namely Salmonella or While admitting that within the term ' diarrhoea' Shigella sonnei dysenteries. The role of E. coli more than one disease was included, Dr. Niven in relation to the disease has not been investigated believed that summer diarrhoea was a specific in this series. It was notable until recently that disease caused by a specific organism. In 1906 he most papers dealing with gastro-enteritis in infancy received a letter from Professor Delepine, of the gave considerable prominence to the part played by Department of Bacteriology in the University of parenteral infection. We were never happy in http://adc.bmj.com/ Manchester, suggesting that: ascribing so much importance to the significance ' Although the bacteriology of epidemic diarrhoea of this factor (Patterson and Smith, 1944) and are is still in an unsettled state, there is a fair amount of evidence indicating that this type of diarrhoea is interested to note the increasing emphasis on gastro- connected with the presence of bacteria of the enteritis as a disease sui generis. Clinically we feel bacillus coli group or of allied bacilli. In this we can recognize with a fair degree of certainty the preliminary investigation it appeared to me that primary case of gastro-enteritis. our object should be chiefly to ascertain to what extent flies were capable of carrying these bacteria on September 25, 2021 by guest. about.' Social Conditions in 1950 This opinion is of particular interest in view of the The names of the 103 patients with gastro-enteritis present work on the role of E. coli in relation to the admitted from the city in 1949 were submitted to the disease. Child Welfare Department. Then a questionnaire The great outburst of 1911 showed that the aboli- was planned and sent to the various welfare centres tion of pails and middens did not entirely eradicate where the health visitors concerned wrote their the disease and other means of propagation had to be comments. Thirty-four of the houses were noted as investigated. A study of the life-cycle of the fly in poor. Sixty of the mothers attended no welfare horse manure heaps was made (Hewitt, 1910). With centre. Both cod liver oil and orange juice were difficulty bye-laws were subsequently amended so given regularly to 32 babies, and 23 babies had that horse manure had to be carted out of the city both occasionally. Eighteen babies had one or the every seven days. Unhappily, there was one other; 18 babies were not given either.
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