Pediatricspediatrics.aappublications.org/content/pediatrics/18/4/...By F. Howell Wright, M.D., and...
Transcript of Pediatricspediatrics.aappublications.org/content/pediatrics/18/4/...By F. Howell Wright, M.D., and...
Presented at Bobs Roberts 1 lospitah for tIme mlm(eting of tIme Anmericaim Aca(hemumv of Pediatrics, October
0, 1955.
663
PediatricsVOLUME 18 OCTOBER 1956 Nu�tBF;mm 4
AMERICAN ACADEMY OF PEDIATRICS
PROCEEDINGS
CLINICAL CONFERENCE
Ulcerative Colitis
By F. Howell Wright, M.D., and John F. Kenwood, M.D.
Department of Pediatrics, University of Chicago
l)mi. \\muculT: I simahl describe a boy withulcerative colitis wimom we have been followimmg
for time last 15 �ears. His fatlmer is of Swedish
extractiomm, Amnericami bormm. He is a very phacid,
iommg-sumfferimig gemmtleman who eumters �‘er�’ little
iumto the picture whmiclm follows. His cciucatiomm
extemiched shighmtiv hievomid time high school level
itS Ime �vemmt to college for 2 �ears at a tech-
ricoh scimool.
Time boy’s iimotbmer, h�’ comitrast, w’as hormi in
Italy. Her fammmilv migrated to this coummmtry wimeiu
shme � ommhv 9 mmmommthsold. They settled in Ciii-
cag() and set tip � closely kmmit famimilv unit wimicim
51)Oke Italiamm roost of time time. His mmmother
grew LII) ummcler circumstauuces wimicim macic her
feel ecmnsiclerably imiferior to persons aroummmcl her.
Sime Imad a \‘ouumiger sister of wimom she was very
jealous durimug time early pirt of her life. She
�1l5() had nmanv feelings of resentment toward
lmer mother fronm wimom she appareumtlv received
little or mmo affectiomm. During imer earl� child-
hood sue had dluml)bed feet whmichm were cor-
rected liv her unotimer 1)i the application of amm
(ml)i)(mr(ttus �vhmicim was 1)ailtftml amid which causedImer to cry a gOOd (heal without reccivimmg mmmumcim
solace fronm hmer mmmotimer. Her eduication cx-tended onlv tlmrouugh grammar schmool, with the
d(l(hitioum (If 2 �ears of secretarial traimming.
After this, sime mmever held a job for any length
of time. Sime workeci sporadically as a waitress.
Shme lived at home with her fanmilv aumd i)eeanme
closely attached to timemmm. 1mm spite of imer feel-
immg toward hmer mother, slme was quite de-
pemmdent upoim her. SIme married whemm sue was
about 23 years old. She seenmed to be �erv
iia�)p\ ill time marriage h)ut almost at ommce be-
came pregmmaimt, aim evemmt for whicim she was
psvclmologicahiv, at least, umot well prepared.
She was fearfumi that sue would not make amm
adle(Iumate mmmothier, aimd that she woumld not be
able to nmeasure up to the standards thmat �)eople
aroummd imer had set for her. She worried about
every criticism leveled at lien.
Time birth of time patient was umormumal. He
was a full-term baby weighing 3.83 kg. His
mother apparemmtlv experienced little (lifficultv
witim him during time first 2 mouths of hmis
life. He was breast fed for about 9 nmoumtims
amid then was shifted directly to time cump. \Vimemm
ime was 2 mommths old, h)ecauuse of her owmi feel-
immgs of propriety, his mother started toilet traimm-
immg i)y puitting the cimild on time potty. By time
age of 13 or 14 mommtlms she had succeeded imm
traimming him during time daytime huit lie was
still wettimug at night. This l)eimavior termmmimmated
when lie was about 2 years old. Dumrimmg his
first 2 years hue imaci a mnuilci case of seborrimeic
dermatitis which lasted (inly a few mnommtlms. His
mother described him as gemmerally beimmg a good
ammd happy infant.
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664 WRIGHT - ULCERATIVE COLITIS
lime Iirst sign ol tli)llh)h( aI)1)(ar(’(1 \VhlVl) lie
��,i(s ahiont 2 v(’ars of ag( �v1memm his :Lp�)etite hc�
gun to slacken. At that time lie was taken to a
Phmysicilmm �Vim() said the child had a mild anemia
arch 1)ktce(i imimumoim sommme sort of iromm mnedication.
At tbme age (if 27 nm(ilmthis lie begamm to imave a
mmmilcl chiarrimea. Time iron medication �vas
stop�)e(l, hut time (hiarrhea commtinued. B� 29
uim(Inths (If age, his (iiarrhmca lm:md bed’Ome l)lO(id\’,
Lmm(l after a month of this he was a(imittcd t(I
time imospitai here for time first time.
No obvious preci1)itatilmg episode for the
hil(I0(i� (liarrimea \V15 (iiscovered. At the time of
imis first aclmissiomm, lie was a well-mmourishecl
and well-developed iumfaimt. The most strikimmg
feature was his (mppc’(mr(tmmee. His mother had
emmcoumrage(l bug, shmoulder-iemigth, i)hack curls
to grow. He was aim immacumlately kept little
h)O\ Who was (1umitc inhibited, very good immhis
(Iumtwardi behavior, Umm(i ‘Who 5(iO�i hiecame a Pet
(If time ward. He had mild alidomimmal distemmtiomm
aimci passed stools which were loose amid bioociy.
The immitial stuudv at that time iimclumded umu-
mnerous stool cumltuumes aum(i examimmatioums for
anmoebae amid parasites, all (If wimich were nega-
tive. In adchitiomm, a pr(ict�sc�p\ � performne(i
rcvcahimmg a granumiar, friable, red muicosa �vimichm
\vas described liv Dr. Kirsimer as heimmg char-
acteristic of cimrommic Im(Immspecific umlcerative
C(Ilitis. A i)ariumm emmema showed mumcosal
chmammges iii time lower i)o\vel, sumpportumg time
diagmiosis.
1mmthe b(I51)ital time child was at first givemm a
low-resicluue, imoim-laxative, high-caloric, high-
vitamin diet. 0mm this regimemm imis stools slowly
improved so that b� the time ime had been iii
the hospital :3 m(imuths it was thmouught per-
missible to discharge him. I imave attempted to
graph his coumrse l)y givimmg a record of time prog-
ress of his height and weight at different ages
iii Figumre 1 ; the top portiomm indicates the course
that imis weight followed, �vhicim is pretty closely
related t(I the exacerbations and remissioums of
his disease.
His mother said that as soon as lie retumrumed
hm(Imne from the hospital there was a chamuge ium
time child’s behavior. He was mmo lommger qumiet
audi �veli behaved. He became much more
active, mmaughtv, amid aggressive. Iii addition, he
began to have emmuresis regularly llmdi to soil.
His diarrhea also returned and, after a brief
peri�c1 at hmomc, he was broumghmt back to thehospital.
At that time time first referral to psychiatry
\�,iLs mmud(hc 101 tht( purpose of evaluating time
lammmilv sitnatr)11. Nothing much c�tmmic of this
becaumse in the process of taking time history it
was determiumed by the psychiatrist that time
patiemut’s mother �vas unable or ummwihhimmg to
accept aumv help.
Toward the sprimmg of timis timird year, theboy contracted measles which was folio�ved 1w
a period of 3 mumoumthms (If remission iii his
diarrhea. Iii the fall when lie became :3 �ears
old, hue had amm exacerbatioum of Imis diarrhea. His
behavior oimce more i)ecame very good. He had
to be admitted t(i the hospital ammd \vas given
a tramisfusion of bloodi. His diarrhea improved,
hue was semmt home, amud his “bad,” provocative
behavior returned.
Duirimug the following winter at our immsistcmmce
he was putt into umursery school. He attemmcied
more or less regumlariv. We fimmailv persuaded
his mother to cumt off his bug cumrls to make
him look more like a boy. Dumrimmg the winter
he did fairly well. He had immternmitteumt bouts
of diarrhea which were umot well couutr(Ihlcd liv
diet, sulfonamides, or other mncasumres cm-
�)lOyed. By the eum(i of time spring lme h)ecanmc
worse.
You will note as a recurrent feature that ime
became worse duniumg the summer mumonths. At
this time he was admitted to the hospital with
rather severe diarrhea which lasted for a
period1 of 3 mouths. Exteumsive attempts weremade to discover some allergic imsis for
his disease. The possibility of immfection was
also reviewed. Although uuothiumg was discovered
which suuggested clefimmite aiicrgeuus, im’ was
placed on a diet free of cow’s milk amid egg
which was contimmumed for several mouths with
cloubtfuml improvemeuut. He was also givensuilfathiazole amud transfusiomms. During the
course of this exacerbatioum his motimer became
mumch uipset amud agreed to proceed witim somepsychiatric help. On this occasiomm she �vent a
little fumrther than before but really dud1 mint
make muich progress.
Duriumg the umext 3 to 4 years, tIme boy
was muot serioumslv incapacitated liv his diarrhea.
He was gemuerailv on a blauud diet. Sumifagumaumid-
imue amid sulfasumxidimme were givemu periodicaiiv,
together with transfumsioums for ammemia. Most(if the time he was able to attemmci school-numrsery school, kindergarten, ammdi themm first
grade. At the begimmmmimmg of his school expeni-
ence, he did not soil himself immschool bumt didsoil himself at home. Later omu, whmeum hue was
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AGE I 2 3 4 5 6I I I I I I
A\IEHICAN ACADENIY OF PEDiATRICS - PROCEEDINGS 665
1I(;. I . lhmmcttm(Ltiomms 1mm tIme 1)nti(nts height ammd weighmt cltmring the first 6 years of life, plotted omi State� of Iowa growth chart. Nuimuhers ifl(hi(ate adinissiomis t(I the’ hospital.
(:i 01. 7 �‘ears (11(1, hic’ was soiling hmimmmsehf at
selmool as \\‘(ih as at imonme. As once again his
mumotimer \vas foummd t(I hi(’ mimakimmg umo progress,
l)SvChmidtliC tre�ttmuicumt �vas t’ruumimmateci for timetimir(l tiumm(’. :\iici again, tim(.’ 1)atiemmts cliarrhct
was �vors� (hiring time suimmnmer thaum at thm’ lie-
giummuimugof time �ear.
If �vc j�t55 along uuumtih time timmme �vhemm hue �vas
S �‘ears 01(1, �vc comime to a �ear in which his
troul)hes l)(gaml to ulmOulOt (Fig. 2). Durimug time
fail of that year he was admmmitte(l t(i this hospi-
tal omi two Occasiolls hweaumse (If severe lil(i(Idi\
chiamrimea. For time first timume, ervtimemmma mu(I(i(Isummm
�tPI)e�tre(i (iii his sums. A suspiciomm of clubbimig
(if iuis fingers was also mioted for the first time.
Proctoscopic cxamimmatiomm was repeated amid the
same mucosal chamuges were observed. H’ ��‘as
trammsfumseci dli(l �vas able to lie in 5(11(101 for a
few months of that �‘ear.
1mmApril amud May, the ammemmuia becamime worse
and the erytimema noclosumm retuirnecl with aim
exacerbatiomm of diarrhea. At this point it was
diecided to 1(lmit imim to time hospital for what
Dr. Cassehs termed a “medical colostomy.”
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666 \VRIGIIT - ULCERATIVE COLITIS
AGE 5 6 7 8 9 10 II 2 3 4I I I I I I I I I I
15 16 17I I I
Fmc. 2. Fhtmctuatiomms in time patient’s height and weight during the period from 6 to 15 years of age.
This coumsisteci of paremmteral feedings, except
for water amid a small amotmmmt of skimmed milk.
He was treated immtravenouisly with Amigen#{174},
j)iasma, gluicose, ammci blood. Suulfommamicie prepa-
matiomms were given liv mouth, and streptomvcimm
immtramumsculanly, imm the hope of reducing the
bacterial flora in time h)owel. This procedure
�vas comitimmueci for a little over 2 weeks and
resulted imm aIm excelleumt remission. Dumrimmg the
sumbsequment summer he �vas quite well. He
joimmed the Y.M.C.A., began to play baseball,and became physically active. This remission
lasted for about 10 mouths.
In April of the year he was 9 years old, hissymptoms returned, presumably following in-
creased bickering at home between the boy
and his mother, and perhaps because he cur-tailed some of his physical activity and at-
tendammce at the Y.M.C.A.
Thinking that we had found the solution to
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AMERICAN ACADEMY OF PEDIATRICS - PROCEEDINGS 667
his problemuus, he was readmitted to the hospital
for amiother “medical colostomy.” This time,
hmowevcr, time 1)rocedure resulted iim relief of
his symptoms ommlv during the time he was iii
time hospital, recurring when he went home.
Fohlowimug these episodes he got aiommg fairly
well for about 2 years. He went back toschool at the age of 10 �ears on a somewhat
restricted diet. 1mm the spring of that year he
agaimm had erythema nodosum. This was found
to be associated with an infected rectal fistula
and abscess. When these were adequately
treated, time ervthema nodosum cleared.
Wimemm he was from 12 to 13 years old, hue
reached a climax in his disease. As you can
see from his growth curve, he began to in-
crease rapidhv in height, presumably due to a
l)rePuberal growth spurt. This was soon con-firmed b�’ the appearance of secondary sex
characteristics. In the fall of the year just afterhis twelfth birthday, he was in excellent phvsi-
cal conditiomu. He had acquired a paper route
amid was making some mommey omm Imis own. He
was cocky, sumre of himself amid, as a conse-
(ltlemmce, paid little attention to his school home-work. Duiring the middle of the �‘ear, because
of his poor school work, he was dropped back
a half year. At first this did not seem to affect
imim very mumch, although he was considerably
puit oumt hiy it. B� April, however, he had a
suddemm, severe exacerbatioum of diarrhea.
1mmadditiomm he lost his appetite, began to have(1iZZV spells, and erythema nodosum reap-
peared. With this, for the first time, he had
diffuse arthritis in the hamuds and feet. Abscesses
imu the skin and a staphylococcic p�uria were
also present. The precipitation of this severe
exacerbation was thought to be due to the
fohlowimmg circumstances : Although his mother
imad muot heen able to accept psvchotherap�,
the boy himself had been seen over the pre-
cedliuig 4 or 5 years at regular intervals
by a psychiatric social worker. In the coumrse
(if treatment, the worker had tried to presentherself as a sympathizing, permissive mother-
figure whose emutire role was to give him affec-
tion ammci coimsole him at all times. 0mm one
Occasiomu, after his school failtmre, she dropped
time hmimmt that perima�)5 � of the difflcuit�
lay with time patient himself amid that if hetried to work a little harder at school he might
muot fail. Actually this conversation took place
jumst a few ciavs hx’forc time suuddcn return of
severe diarrhea.
At this point ime was again admitted to time
hospital and was successfumhly brought through
this exacerbatiomm. He weumt t(i summer school
with the hope of making up lost ground amidrejoining his class. However, he resemmted summ-
mer school so much that he not only did notsucceed in making up his work but iii additiomm
had an exacerbation of diarrhea. During thelatter pant of this summer he dechimmed to timelowest point in the course of his ihimmess. As can
be seemm from the marked dip iii the weight
curve, hue lost weight just before time age of
13 years. Pyumria developed agaimm. He imad
edema of the feet, severe abdomimmal paimm and
severe biood�’ diarrhea.
He was again admitted to the Imospital irmwhat appeared to be a seniouis coum(iitiomm. The
first night in the hospital he thought thimmgs
over and walked out. He stayed home for
about a week in a senioumslv ill comudition before
hue finally �ielded to his parents’ demands that
he return to the hospital. A proctoscopic exami-nation disclosed a draimmimmg rectal abscess. He
was treated with antibiotics and traumsfumsions.
His fever remitted amid the infectiomm cleared,bumt the arthritis, which had returned togetherwith edema of the feet, commtinued. At this
time it was decided to umse ACTH. After one
dose had been administered lie agaium left the
hospital iii a huiff. Within 3 weeks after
he walked ouit, he had improved to the point
where he was able to go back to school.
From this time on, physical improvememitwas progressive and maintained. As can be
seen from the curve, his weight went up, reach-
ing the top hue, and stayed there. He suubse-
quenthv went to high school where lie was
much interested in sports and actively played
football, basketball and baseball, making the
high school teams in both h)asebahh amid basket-ball. His school work was mediocre amid huefinished the course with difficumltv. Dumriumg this
time euuumresis contimuumed amid! occasiomual soilimug
occurred. The exact extemut of diarrhea is muot
known because he would imot reveal it to amuy-
omme. We can only guess that some diarrheawas presemut becaumse his mother reported pen-
odic episodes of soiiimmg and ciiarnhmcal stools.
He continumed to see time psvcimotherapist pen-odicahly, hint umot at regular immtervahs. At home
his behavior became aiarmimiumg to his 1)arents.
He was very demandimmg. He stole mommey from
his parents, took the family car withmout per-
missi(imu, amid refused to comtfornm to any of the
rules or regulatiomms laid down for imimumat home.
In spite of his behavior at home, lie mmever got
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668 WRIGHT - ULCERATIVE COLITIS
imito any tuOUh)le with the civil aumtimorities umor
��‘as there ami� report of serious troumble at
school.
Fimmahly, timis past summmmmner Ime reached aim age
which permitted him to joium the arms’ which
ime l)m�mPtl\ dud. Now he is off imm camp wait-
iuig for the arm� to (liscover that he has uulcera-
tive colitis.
So much for time pr�tntcteci hmist(irv. I �visii
imow to make a few brief comummemmts about some
of the featuires of this patieumts history.
As yotm will have imoted imm Figure 1, this
hio�s growth was really mmot iimterfered with iii
a permaument fashiouu. The height followed the
middle curve ummmtil lie reached puberty ummcl
then imucreased abrumptl� to the tipper himme. The
weight vacillated aroummici the midlimme and
finally, witim 1)ubentv, ascemmded to the himme
indicatimug 1)ltms Olie stamidiardi deviation . His
clevehopmemmt, immteilectumallv ammd physically, has
been umormal throughoumt. His inteliigemmce
(luotiemmt has i)een ummeasumred at 1 18. Physically,as I related, lie imas beeum ahle to participate
in very active 51)oIts.
The course of the anemia is rouighmly related
t(i the exacerbations amid remissioums (if the clis-
ease bumt ui(it exactly so. There have beemu times
wheum he was immoderately anemic taut withouut
symptoms, aui�i there have I)een times wheim lie
had severe symptoms �vithoumt ammemia. Jim the
couirse of time last few years lie has had mmo
sigmuificamit ammenmia.
Several roentgeumogramums of time coloum showed,
at first, mucosal changes iii the lower rectosig-
moid, later on, changes imm time descencliuug colon
amud portioums of time transverse coioum, buit not
mumclm aclvaumce in the severity or extemmt of time
lesiomm over time years.
A few wordls should be said ab(iumt the effec-
tiveimess of the treatmemmt. Dumnimmg most of the
15 �ears �ve have beemm trvimmg to correlate
timerapeutic measures with chaumges iii time dis-
ease. By ammd large, �ve have l)eemm fruistrated
in this attem1)t. Certainly, traumsfumsions made
him feel better whemm hue was ammenmic, amid meas-
tunes used to decrease the diarrhea were umsuahly
effective. On the whole, however, neither diet,
vitamnimus, iromm therapy, mmor sulfommamides pro-
dumced aumy rehiahile, iastimmg chaumge iii the state
of his colon. At times he actumahly seemed to
improve when he refumsed to accept the treat-
meumt of the doctors. For instamice, whemi omm
restricted diet at omie poimmt hue was havimug
immoderate diarrhea, l)ut �vimemm lie mefuseci to
follow the diet, imis mmmother yielded and gave
him a gemmeral diet, amid he immediately im-
proved. Similarly, in the last hospitalization
(hescnibedi, he was iii severe straits, bumt ne-
belied, walked out of the hospital, amid stir-
prisiimglv became progressively better.
We have failed to demonstrate aim� specific
infection to lie the etiology of the disease.
Them�e has beeim mmo suspicioum of vitamin defi-cieumcy, amid attempts to demomistrate allergy
were mmot fruitfuil.
The significance of the erytheimma nodosumm
amid arthritis is open to commjecture. 0mm at least
three of the four occasions whemm he had
enythema mmodosum, there was an associated
pyogeumic immfection present either in the urinary
tract or iii the wall of the bowel.
Some of the characteristics of this boy’s per-
sonalitv amid of the family situatiomm are inter-esting. Dr. VamudenVeer who followed him dun-
ing most of the illness thoumght that oume of the
major mechanisms was immternalization of hostile
amid aggressive feeiimmgs. Whemm he was uumable
to discharge emotiommai tension liv the usumal
routes, diarrhea developed. Some suipport for
this thesis camm be observed immthe course of the
disease. When his behavior was good, diar-rhea was severe, and conversely whemu diarrhea
was umider commtrol his behavior teumcled to be
bad.It seems to me as I have watched him oven
these years that he maintains a very brittle
sort of adjustment. He is better off when he
caum emmgage in vigorous activities which presum-� ably give vent to some of his emotiomms. Yet this
brittle adjustment leads to periodic troumble
with his eumvironment and sets off aim exacerba-
tiomu.
Omue final commeumt should be made about
the similarity between the childhoods of theboy amid his mother, amid the similarity of theirpersommahities. The mother, whom I have iii-
adequatei� described, is a very temmse, cmi-trolleci sort of individual most of time time, very
dependemmt, and fnequuentlv having coumsiderable
concealed hostility and anxiety. The boy him-
self has a similar disposition. Neither of them,
appaneumtlv, had aim appropriate quota of affec-
tioum from their respective mothers.
At this poiumt I �voumld like to tumnum the ciis-
cuission over to the psychiatrist, Dr. Keumwood,
who has had extensive experience with chil-ciren stiffening from umlcerative colitis.
Dii. KEN�VOOD: Actually, I have not had a
large series of patiemmts. Four have beemm stumdied
intemusively iii the last 2 �‘eans. Two of the
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A\IEIIICAN ACADE\IY OF PEDIATRICS - PIIOCEEI)INGS 669
(hlih(hmiIm ��‘erc v(ry mmuumchu inuprov((l, t\V() ol
theni I think (0111(1 l)C class(’(l �LS cured. One
camumiot say as vet that thie�’ �vihl n(It have cx-
accri)atioums, bumt as of this p:irticumlar momemut,
tW(I (‘iiih(hremi have had mmo retuirmm of their svmp-
torus for time past 9 nmonths.
It is (if interest that as timese cimildremm improve
sommmaticahiv, emumotuiumal prol)lems ma� lie han-
(lied! ium a mucurotic �vay. For instance, one \V�t5
iii recently in aim actmte auuxictv state, limit at
least time h)o�vel (.(Imfl})l�timit hid(l not hicgumum again.
Ouue (xl)ert in this particular field bias said that
thU way (II1C treats this sort of timimmg is to tr’t’
to ummake time 1)itient umeurotic, giving a psvcimic
rather timaim a somatic ouutiet, amid themm treat themleuurosis hater oum. Neither aim acute aumxietv at-
tack uior uk’erative colitis is pleasauut, hint at
l(’dst anxiety is muot goiumg to kill the patiemmt ammch
C(Ihitis mmmight.
\\Tc have foumnd a remarkable similarity
tiiiouig time pirents (if these chiidremm. Wheuu Ifirst hiegan t(I m�ike obsenvatiomus iii this p�1r-
ticular field, I was t(Ildi that these paremmts wene
ahi’�ohumtelv hi(iITIeicss, that we umuight as well not
c(Imisi(ier thmemim hiumt plaum to treat time children
imitemmsively �timd then place them imm a foster
hmomne. I have commue to completely disregard
thuis 1)hiii�50phm\. \Vhat I imave fotmmmcl, immgeneral,
is that thmesc’ parcmmts, at the tinme of time dhildls
h:rthm, were un(ler a 1)artidular stroumg extermmah
stress, so great that they felt their own lives��‘c’rc iii danger. Basically they were fairly
souuui(l I)eopl’ hiuit the external stress interfered
�vithm relatiommslmip �vithm timis particni:mr cimild.
This is �im�l�cttc�i liv time fact thmat (II1C sees the
other cimilcireum in time same family d(Iimmg quuitc
nicely amid imavimig no sigmm of timis kind of
trouble. \Ve hmay.’ foummd that we camm work with
thmese 1):Lreumts. In those cases where we (1(i con-
red’t time situmatioums at hommme, we have a mucim
hettcr chmammc’ of suiccess. 0mm time �vhuole, I have
foummd time paremmts (1uiite co-operative.
You mimav imave hmear(l specuhatiomm that umicena-
tive colitis is prohial)iv related t(I toilet traimmimmg.
1 think it safe to say timat it is related to the
toilet traimiimmg period because this is the clisci-
phmmarv 1)eriod iii a cimild’s life, but it is not
related to time t(Iihet trainimug per se. In almost
ever� case we have found that toilet traimming
��‘as not heguim t(iO eanh�, muir �vas it carried
On 1)umliitiyelt. Bumt some external evemmt will be
fonuud to have disturh)edl the relationships iii the
faummilv ; for immstammce, iii omme case the voummgster
��‘as turmmecl over to a maid for toilet traimming
time very week that time mother left honme. So
it is �O)i11( (iI(’IImmiSt.LiI(C Othi(’I than time toilet
training its(’l1 tlmat is sigmiifmcant. \Vc have
foumid in every case timat there were feedimmg
difficulties, often severe, night from imufancv.The majority (If these chmiidreum, in various
ways, are mmot at a loss to express hostility, as
all of the nurses, doctors amid others who deal
with them are well aware. What I thiuuk is im-
portamit is that tlme� hmavc difficuultv expressimughostility against the very person who, perhaps,
is the most importamit to them. What we are
trvimmg t(i (10 15 to correlate their dispha� of
emnotiomu imm curremut situuatiomms with the labora-
tory (lata. Oume of the chiidremm showed mmo im-
i)rovemeuut until omme day wheum she “blew uup”at a nurse oven taking her bath. Actually, as we
traced it hack, this was the first time that she
had showmm any hostility toward a womami at all.
She centaiuuhv had been hostile witim nme, amid1
she had been hostile with other mcii iii time
eumviroumment, i)tmt not wth womemi. But the’
notew(inthy aspect (if this incident was a rise
in hemoglobin which begaum very shortly there-
after. All of these voumumgstens have beemu down
to 5 t(i 5.5 glum. of hcmogiobium amid, as aim aver-
age, 5 mouths after the start of psycimo-
therapy, the hemoglobumm begaum to rise. Thus
ma� be the very first eviclemuce seen of aim’s
improvememut in time disease.
The last symptom to disappear is the bowel
symptom, wimicim I consider a very imiterestimmgaspect. I certaimmly do mmot ummderstammd it, buut
this disease is not coumfiumedl merely to time bowel.
Mammy (if the amuemias are of a iuemolvtic type
ammcl are not related (hirectly to time loss of iilood,
for grossly time’ 1(155 of i)h(iod commtimmumes at the
same nate amid vet time imemoghoi)imi ‘svill rise.
Omme other cimaracteristic of these childnemi is
that they are exceedimmglv (lemamm(limmg. The�’ will
drive �otm stark, raving mac! if youm tr�’ t(i
satisfy all of their whims. They have a bottom-
less pit as far as needs are concenmmed. I do umot
believe iii i)eimug excessively permissive with
these �‘oummgsters, but I think initially omme has
to allow a certain amoumumt of aggnessiomm amid
greediness. Shortly thereafter, one has to bring
them iumto a normal, socially acceptal)le pat-
tern. This is very chifficumit aimcl takes time and
Iiatiemice. At the same time, orue mtmst lie very“giving” to these chmiiciremm, liv whicim I meamu
that omme must become aim ideal paremut to the
best (if one’s ability. I have takemu these children
to the zoo auuci to shows and vanioums such
thimmgs. One practically lives with them. But
evemmttmJly, they leanmm to commfine their demamuds
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670 WRIGHT - ULCERATIVE COLITIS
‘svithmiimtime l)(IIlim(lsof a m(’asolmahile social stitic-
ture.
I thimmk ammother very important component
imu timese votmngsters is sexumal conflict. I suspect,although certaimmiy camm’t prove it at this momemmt,
that there is a sexual trigger which sets off this
disease.
In ciosimmg, Dr. Wright mumemmtioned that this
hov temided to recover when he was placed on
a free, general diet. The youngsters that we
had in a more or less coumtrohled environment
were placed omm just this kind of diet. They
were mmot restricted in any way so that for weeks
and months they practically lived on wieners
and hamburgers, with tremendous amounts of
mumstand, catsup, etc. Furthermore, almost ever�,’
single itemit of forbiddemm food was time very one
they wanted over a period of tinme. Gradually,
they retunmmed to a good diet, even though in
some cases it took a year or more, and I am
firmly convinced, without harm to them or
the bowels. Tnyiimg to emmforce a rigid diet omi
these youngsters caused more damage to their
emotional state, increasing the feeling that the
whole world was against them and that they
were being deprived. The free diet at first
caused doubts and shudders in the staff, but inthe long nun, I believe the results were very
good.
My whole attitude about this particular dis-
ease is, that while work with it is very diffi-
cult, the prognosis is excellent.
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1956;18;663Pediatrics F. Howell Wright and John F. Kenwood
CLINICAL CONFERENCE: Ulcerative Colitis
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1956;18;663Pediatrics F. Howell Wright and John F. Kenwood
CLINICAL CONFERENCE: Ulcerative Colitis
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