MANAGEMENT OF THE ALIMENTARY TRACT IN PNEUMONIA


The enthusiasm of some over the “discovery” that serological methods and results are “homoeopathic in principle” is so naive as to suggest that they are really moved, perhaps subconsciously, not so much by a desire to strengthen homoeopathy, as to exculpate themselves for abandoning its established technic and adopting the newer, more impressive and more popular hypodermic method.


(Editors Note. Many of our apologists, defenders and propagandists have expected themselves to find illustrations or confirmations of homoeopathic principles in allopathic literature. The most popular and frequently used source from which they drawn in recent years has been the Department of Serology.

The enthusiasm of some over the “discovery” that serological methods and results are “homoeopathic in principle” is so naive as to suggest that they are really moved, perhaps subconsciously, not so much by a desire to strengthen homoeopathy, as to exculpate themselves for abandoning its established technic and adopting the newer, more impressive and more popular hypodermic method.

Be that as it may, the emphasis laid upon serological methods does our apologists little honor and is unjust to our allopathic brethren, since it gives the impression that serology is their sole or main reliance in the treatment of disease, and that they have made little or no progress in other departments of therapeutics.

The fact progressive allopathic clinicians do not depend solely, or even to any great extent, upon serology. Many of them are opposed to it except perhaps in diphtheria, typhoid and syphilis, and even in these diseases they advise great caution. They are fully aware of the dangers of indiscriminate drugging, serumizing and vaccinizing, as shows by biological research. More and more the are coming to depend upon simple, natural, hygienic and dietetic measures which they have studied and developed to a high degree.

This and the following article by one of the most progressive and highly esteemed allopathic clinicians of Brooklyn will serve to illustrate the foregoing remarks, and help, perhaps, to restore the mental balance of some of our wavering brethren.

Parenthetically it may be remarked that when Dr. Cornwall says “no specific drug treatment for pneumonia has ever been or is ever likely to be found,” he is in complete agreement with all authorities on homoeopathy. No competent homoeopathician ever thinks of or seeks for a “specific for pneumonia” nor for any other disease, for he knows it does not exist. He seeks only for the drug which in its effects upon the healthy the individual organism, is symptomatically most similar to the symptoms of the individual patient, confident that when he has found and used it, he will get curative results. “Specifics” are only for the individual, not the class).

Between the group of cases of pneumonia which die no matter what treatment they receive and the group that gets well anyhow, lies a considerable group whose mortality rate can be influenced favorably by treatment along right lines. Such treatment does not mean specific drug therapy, for no specific drug treatment for pneumonia has ever been or is ever likely to be found; and biological specific treatment, although bright with hope, has not yet emerged from the experimental stage. The best treatment now available consists in physiological support.

Physiological support must not be confounded with symptomatic treatment, for symptoms do not always call for ablation, being often manifestations treatment, which is negatively correct but often deficient positively; and it must carefully excluded meddlesome therapeutics. Its principle dominates or should dominate all therapeutics.

Particular opportunities for physiological support in pneumonia present themselves in the management of the alimentary tract, from which threaten toxemia, tympanitis and reflex nervous disturbances. After securing rest in bed, the first therapeutic duty in this disease would seem to be proper management of the alimentary tract. In this management we have to deal with questions of diet, catharsis and disturbing medication.

Diet.

In feeding patients during the active period of pneumonia we are not under the necessity of maintaining full nutrition because that period is regularly short. We can with advantage and safety reduce the rations of protein and fuel to half the ordinary requirements in the average case; and in severe and complicated cases we should make greater, perhaps much greater reductions. The rations of the salts call for special consideration because of the shortage of calcium which seems to be regularly present in pneumonia and the tendency to acidosis inherent in febrile diseases.

The water ration should be liberal to facilitate free elimination, but on the other had if the heart shows weakness, the indication to favor the heart by restricting fluids is present. The unqualified order to “force fluids” should not be given in this disease. As regards the general quality of the diet, it should first of all be fluid and lactovegetarian, that is, should contain besides salts and water only articles from the vegetable kingdom with addition of milk and it products. Other animal foods are contraindicated on account of the danger from intestinal toxins.

Animal broths and raw egg albumin are particularly objectionable, as are the patent foods which feature the words “peptone” and “peptonoids.” The growth of acidophilic as against saprophytic types of bacteria should be encouraged in the intestine. When milk is given it should be modified so as to safeguard against indigestion. The dietary may well be safely limited to modified milk, cereal gruels, strained fresh fruit juices, salts and water. The following is my standard full diet for pneumonia.

Full Pneumonia Diet.

At 7 a.m. Give 7 ounces (21 gms.) of a two-to-ne mixture of milk and barley water or other specific cereal decoction, to which has been added 5 grains (1/3 gm.) of sodium chloride and 5 grains (1/3.) of sodium bicarbonate.

At 8 a.m. Give 7 ounces (210 gms.) of water in which has been dissolved 10 grains (2/3 gm.) of calcium chloride or lactate.

At 9 a.m. The same as at 7 a.m.

AT 10 a.m. Give the following mixture. Strained juice of orange, grape-fruit or pineapple, 2 ounce (60 gms.) lactose, 2/3 ounce (20 gms.), and water 5 ounces (150 gms.).

At 11 a.m. The same as at 7 a.m.

At 12 m. The same as at 8 a.m.

At 1 p.m. The same as at 10 a.m.

At 2 p.m. The same as at 10 a.m.

At 3 p.m. The same as at 7 a.m.

At 4 p.m. The same as at 8 a.m.

At 5 p.m. The same as at 7 a.m.

At 6 p.m. The same as at 10 a.m.

At 7 p.m. The same as at 7 a.m.

If desired the three fruit juice feedings may be given in the night instead of in the day.

This dietetic prescription supplies daily about 38 grams of protein, fuel of a value of about 1200 calories, about 2 grams each of sodium chloride, sodium bicarbonate and calcium chloride, in addition to the salts naturally present in the articles of food given, and about 2700 grams, or 90 ounces, of water. It is a maximum diet, except as regards water, which might in some cases be increased in amount, although much more frequently lessening of the amount of fluid is called for.

Modifications of this full diet are often required, as in the following conditions.

When the disease is severe it may be desirable on general principles to reduce the number of the milk feedings or omit them altogether; and regularly near the expected time of the crisis, except in mild or very favorable cases, the diet should be reduced, usually by omitting the milk and restricting the fluids. Extra fruit juice feedings may be given in place of specified milk feedings. A diet of water and strained orange juice with addition of calcium and sodium salts is the diet of safety.

If signs of heart failure appear, as rapid pulse, irregular heart action or pulmonary edema, the fluid should be restricted and perhaps the milk omitted.

Diarrhoea and tympanites call for reduction of the diet to barley water, water, orangeade and salts, or to water and salts alone, or to barley water alone. Patients fed according to the plan above described rarely show diarrhoea or tympanities.

Catharsis.

The delusion that catharsis has a therapeutic value per se was fostered by the old humoral pathology; it still seems to exert a considerable influence on medical practice, judging from the extent to which catharsis is routinely employed in the treatment of many diseases; it works particular harm in pneumonia.

While regular daily evacuations of the bowels are conceded to be desirable in normal conditions, it is well known that nature frequently constipates fro a constructive purpose, as in typhoid fever and appendicitis. That cathartics by increasing the fluidity of the colonic contents favor production and absorption of intestinal toxins is an inference from certain observations which have been made. That the development of tympanites in pneumonia may be favored by the use of cathartics is a conclusion based on clinical observation as well as priori reasoning.

That the frequently unstable condition of the heart in pneumonia renders particularly dangerous the vagus stimulation which accompanies artificial evacuations of the bowels seems good physiology. That the bowels may remain unmoved for a considerable time more safely with the diet above described than with one which contains preparations of animal flesh and eggs, is not difficult to understand in the light of our knowledge of the biology and biochemistry of the intestinal canal.

The above considerations suggest as a safeguarding policy in management of the alimentary tract in pneumonia, conservatism in the use of artificial bowel evacuants. This does not mean that cathartics or enemas should never be used in this disease; it means that they should not be used in routine fashion, but only to meet special indications for their use other than the fact that a daily evacuation has not taken place. It is held with moderate constipation, the diet being as above described, there is less danger of the occurrence of toxaemic disturbances, of tympanites and of heart failure, than when regular daily evacuations are artificially induced. It is held that purgation, especially with salines, even at the beginning of the disease, can predispose to toxemia and tympanites; and that later in the disease it may precipitate heart failure. The dangers from constipation, within limits, are considered less than those from routine purgation.

My positive practice in regard to evacuating the bowels in pneumonia may be summarized as follows: If the patient when first seen has nor had a satisfactory movement within twenty-four hours, and the disease is in a comparatively early stage, and no contraindications are present, an enema is given; after that attempts to move the bowels during the active stage of the disease are made only when special indications appear. Among such special indications are tympanites which regulation of the diet does not correct, and an uncomfortable sensation of fullness in the rectum complained of by the patient, both of which are of comparatively rare occurrence with the diet above mentioned. In fact, it is the rule for patients fed as above mentioned.

In fact, it is the rule for patients fed as above described and otherwise managed in accordance with principles laid down in this paper, to show soft abdomens and to free from abdominal discomfort in the absence of bowel evacuations for considerable periods. It often happens that evacuations take place naturally, and these do not seem to disturb the patient as do the artificially induced ones. For moving the bowels when needed I use a simple or a soapsuds enema or an enema of a pint of warm water in which has been dissolved a drachm and enema of a pint of warm water in which has been dissolved a drachm and a half of powdered oxgall.

Regularly on the second day after defervescence, if the bowels have not moved naturally, an enema is given. If there seems to be impaction of feces, which is sometimes found in cases which were constipated from the beginning of the disease and were not relieved because of their critical condition, the following procedure is used in the early convalescent period. An ounce of castor oil is given by mouth and at the same time six ounces of warm olive oil are injected into the rectum, to be retained. Four hours later, if a satisfactory movement has not taken place, the fel bovis enema above described is given. Two hours still later, if the condition calls for it, a colonic irrigation is given. In cases of severe and obstinate tympanites pituitrin has been found to act beneficially.

The policy of not moving the bowels in pneumonia unless special reasons exist for doing so, was recognized and adopted by me about the beginning of the year 1913, and since then I have followed it strictly in my treatment of this disease. The results seem to justify this policy. In a continuous series of cases covering six years, treated by me in accordance with this policy in one hospital immediately after 1913, the gross mortality was less by more than one-third than in a similar series treated by me in the same hospital in the six years immediately preceding 1913, in which this policy was not followed. A more recent series of cases gives an even better showing.

Disturbing Medication.

The proper management of the alimentary tract requires avoidance of medication disturbing to it. In dealing with this phase of the subject I realize that I am on difficult ground, for everyone would not agree on what constituted disturbing medication. Medical traditions, individual pride of opinion, obsessions in favor of particular treatment, to say nothing of insufficient knowledge of normal and pathological physiology, tend to dull observation and confuse judgment. Therefore, the statements made here regarding medication disturbing to the alimentary tract are made as statements of opinion, and their intrinsic reasonableness is relied on to give them authority. The following are cited as examples of such disturbing medication.

The routine use of purgatives. This has been discussed in the preceding section. The practice of beginning treatment with a dose of calomel followed by a saline purge, which has had an extensive and long-continued vogue, appears a flagrant example of this disturbing medication.

“Digitalizing the heart,” This procedure, which more or less disturbs the alimentary tract, can be justified only by greater good to the pneumonia and in the prophylaxis of heart failure in that disease, is questionable.

The use of “cough mixtures.” While opiates have a restricted and special use in pneumonia, and in particular, to quiet a very harrassing dry cough early in the disease, the “mixtures,” especially if they contain “expectorants,” can disturb the alimentary tract without compensating benefit.

It may be said that any medication which disturbs the alimentary tract in this disease should have extraordinary value to justify its use; and there seems to be very little such medication used in pneumonia which has extraordinary value. Fortunately it is possible to meet many important emergencies in pneumonia for which medication in the present stare of our knowledge is indicated, by using agents which do not disturb notably the alimentary tract.

In conclusion I wish to emphasize the supreme importance in therapeutics of the principle of physiological support. We become better physicians as we learn to harmonize our therapeutic activities with this principals.

1218 Pacific Street.

Edward E. Cornwall