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.
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