Pediatricspediatrics.aappublications.org/content/pediatrics/18/4/...By F. Howell Wright, M.D., and John F. Kenwood, M.D. Department of Pediatrics, University of Chicago l)mi. \\muculT:

$Page 1: Pediatricspediatrics.aappublications.org/content/pediatrics/18/4/...By F. Howell Wright, M.D., and John F. Kenwood, M.D. Department of Pediatrics, University of Chicago l)mi. \\muculT:$
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.

by guest on July 1, 2018www.aappublications.org/newsDownloaded from

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


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.”


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


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



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


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



‘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.


1956;18;663Pediatrics F. Howell Wright and John F. Kenwood

CLINICAL CONFERENCE: Ulcerative Colitis

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