Stosstherapy in Acute Respiratory Infection in Children
Authors: M. C. Joseph
Journal: BMJ (1958)

Stosstherapy was the name given by Harnapp (1938) to the method of treatment of rickets with a single massive dose of one million units of vitamin D. Later, Gaisford (1951) used the name to describe the single massive dose of sulphonamide which he used in the treatment of pneumonia and other infections.In Denmark and America this method of treatment has been called " shock dose."Although stosstherapy is a relatively new method of treatment, Ehrlich (1913) was well aware of the ad- vantages of cure by a massive single dose, the therapia sterilisans magna: " We must give strong doses, accord- ing to the maxim Frapper fort et frapper vite."In fact, Ehrlich had some success with stosstherapy, for a 300-bedded hospital in Surinam, used solely for the treatment of yaws, was emptied.The first published report of stosstherapy in the treat- ment of respiratory infection in children was by Platt (1940).He used sulphapyridine in a single dose of 0.3 g. per kg., up to a maximum of 4 g.Patients treated during the same period with multiple doses formed a control group.He reported good and comparable results in the two groups.Since then other reports of satisfactory results from stosstherapy have followed (Karelitz and Weinstein, 1940; Vollmer et al., 1944; Lauria, 1947; Wilken-Jensen, 1948; Friderichsen and Walther, 1950).The last-mentioned authors began using stoss- therapy in 1941; from 1944 they used sulphathiazole instead of sulphapyridine, and after 1946 for 39 children they used penicillin in addition to sulphathiazole.By 1949 they had treated 1,500 children by stosstherapy.875 of their patients had pneumonia, 90 lobar and 785 bronchopneumonia, of which 280 occurred in infants under 1 year of age.The case fatality for the 875 children with pneumonia was 4.9%.Jersild et al. ( 1956) treated 245 children with pneumonia with a single dose of 200,000 to 400,000 units of procaine penicillin, and compared the results with 323 cases of pneumonia treated with injections of procaine penicillin twice daily for five days; the single dose was as effective as the five- day course.Material and MethodsThe object of the present stuidy was to compare the results of stosstherapy in acute lower respiratory infection in children with those of standard continuous chemotherapy.Between October, 1952, and October, 1954, 174 children with acute lower respiratory infection were admitted to the Evelina Children's Hospital of Guy's Hospital, and were treated with penicillin by injection or oral sulphonamide, or a combination of both.Sixty of these were treated by stoss- therapy and 114 by a conventional continuous course of chemotherapy.It was necessary to exclude certain patients from both treatment groups.From the stoss group of 60, 8 children were excluded (2, hilar adenitis; 1, whooping-cough; 1, mongol; 1, staphylococcal pneumonia; 1, middle-lobe col- lapse; 1, treatment delayed 16 days; 1, bronchiectasis).From the standard group of 114, 60 children were excluded (41, duration of penicillin less than five days; 10, treated with sulphonamide only; 5, chest films mislaid; 1, aged *Based on M.D. thesis for University of Cambridge, 1957.2 weeks; 1, fibrocysic disease of the pancreas; 1, death within one hour of admission; 1, agammaglobinaemia).After these exclusions there remained for the present study 52 children in the stoss group and 54 in the standard group.The method of treatment (stoss or standard) to be given was chosen by any one of fourteen doctors who admitted the patients and whose personal preferences dictated his decision.The grouping of patients who clinically appear to have an acute infection of the lower respiratory tract is not easy, whether aetiological or anatomical classification is attempted.For simplicity in this article, the patients who clinically had an acute infection of the lower respiratory tract were grouped by radiological appearances: group la, consolida- tion confined to bronchopulmonary segments; group lb, con- solidation confined to whole lobe; group 2, consolidation not confined to bronchopulmonary segments, (a) discrete, (b) confluent; group 3, no radiological changes.Comparability of the Two Treatment Groups.-TableI shows that the two groups on admission were similar in respect of clinical and radiological grouping, age, sex,