Common sense medicine, recognizes and honors the wisdom of the body that we have acquired in living over the generations, and asks: "What is the body trying to do here?"
This questions has not been asked in western medicine because our framework, or paradigm, is based on balancing the body's symptoms. When something is wet we dry it; when something is hot we cool it. We inherited this paradigm from the ancient Greeks along with many of our other social structures. The Greeks began the concept of humoral medicine. When a person had a problem the doctor decided which of his humors was acting up and used drugs and other means to reduce that humor. When the patient was flushed and feverish he was considered to be too sanguine and his arm was cut so that he could bleed. The loss of blood led the body to try to save blood for the more important internal organs by shutting down the circulation to the skin, so the flushed appearance was successfully treated. And if they took enough blood the shock would eliminate the fever. It was very effective therapy for the symptoms, and, as we know today totally wrong.
In this section I look at two "problems" that we have dealt with by developing medications that block our normal body processes. The question, as it was for bleeding, remains: "Is this a wise thing to do?" Joseph Chilton Pearce, in talking about "The Roots of Intelligence" distinguishes between intelligence and intellect. All living things have a degree of intelligence. Lewis Thomas, in his best selling book, Lives of a Cell, talks about the intelligence of cells. Intelligence will not let us do something that will harm us. Intellect, on the other hand, is only constrained by, "Is it possible?" For the last 50 years our educational system has been geared at training the intellect in order to have people capable of destroying the earth by nuclear war or more slowly by environmental destruction. I believe that doing things that block our normal body defenses is a good example of unrestrained intellect —of intellect, in Pearce's words, "totally devoid of intelligence."
If we ask why certain symptoms develop, as biologists are currently doing, we learn that the symptoms can generally be classified as defenses, manipulations, or side effects. Defenses are symptoms that actually help us deal with insults such as fever, diarrhea, and a runny nose—we benefit. Manipulations are symptoms that are stimulated by and benefit the invading organism, such as the prostration associated with malaria, that makes the person an easy target for hungry mosquitoes, or the enhanced diarrhea of cholera that spreads more of the bacteria into the contaminated water supplies—the bacteria benefit. Side effects, such as the dry eyes of a person with Bell's Palsy or the hot flashes of menopause are just that—neither side benefits. Side effects can be treated without problems, manipulations need to be addressed by making the transmission more difficult—mosquito nets and clean water supplies for the examples given—but defenses need to be honored and assisted.
Every animal with a backbone, and some without, can develop a fever. This is usually a response to infection from bacteria or viruses. Most people realize that there must be some advantage to a fever in such circumstances. And there is. The immune system is responsible for keeping us healthy and it does this much more effectively and efficiently when we have a fever. Rabbits die more often from the infection when their fevers are blocked. Similar studies have not been done on humans because the "harmful effects" of fevers have been too widely accepted, but there is some indication that blocking fevers by using drugs like ibuprofen actually increase our chances of becoming septic with serious infections.
Febrile seizures are one of the more fearful consequences of a fever in a child. I remember one of my mentors who was talking about febrile seizures. "If you see a child with a febrile seizure," he said, "FOR HEAVENS SAKES, DON'T JUST DO SOMETHING, STAND THERE." Febrile seizures do not harm the brain of the child experiencing the seizure. The rub, of course, is knowing that the seizure is caused by the fever. Since other causes of seizures can cause problems in the brain we must treat unless we are certain. Several studies over the past two hundred years have shown that people can tolerate high temperatures without problems. Most of these studies have been done by warming the body from outside in sweat lodges or military gear and the people were in good physical condition. By far the most important thing these people did as their temperatures went up was to drink.
This is also the best thing to do when anyone has a fever from infection. Over the years that I have worked in the emergency room I have seldom seen anything make people feel better when they are ill, from almost any problem, than an IV. So drinking is the best thing to do for a fever. And make the person as comfortable as possible. If that means they bundle up in bed with the electric blanket on high, that is probably OK. If they ache all over acetaminophen can help, but it will also lower the temperature. Again, the best thing to do is stay really well hydrated so that your body can wash out their infection more effectively. For me this means ORAL REHYDRATION, which brings us to our next topic.
Whenever something irritates the bowel the body responds by trying to wash it out. Again, for the body, the solution to pollution is dilution. This problem, as much of a nuisance as it is, is a normal defensive process. When it is caused by Shigella and we take medication to stop the diarrhea we do promote more problems - more of the bacteria set up housekeeping in our gut. A large part of the people who suffer from irritable bowel disease have had an episode of infectious diarrhea before the onset of their irritable bowel. I wonder how many of them used pharmaceutical agents that slow gut movement during this illness. My own personal experience using oral rehydration is that the diarrhea stops faster and people usually feel better faster than with any other way of dealing with diarrhea.
One of the real success stories of the last century is one that we don't often hear about. Public health efforts in this country have largely prevented the cholera epidemics that we had in the 19th century. Less developed countries continued to have these epidemics until the latter part of the 20th century. A single epidemic would often cost hundreds and sometimes thousands of lives. Oral rehydration was developed in the 1960's and 70's as an adjunctive treatment for cholera. In fact it is the only treatment necessary. People with cholera don't die from the bacteria or from the toxin it releases; they die from dehydration. The immune system knows that the toxin will kill us if it gets inside the tissues and organs of the body so it opens every conceivable tap to wash it out. This takes water from other critical places in the body damaging the function of the heart, brain, and kidneys that leads to the death of the patient. We routinely give antibiotics to people with cholera because it cuts the time they shed the cholera bacteria from about four days to about two days. But the only treatment they need is fluids. With epidemics involving thousands of people there were not sufficient resources either in IV solutions or in people trained to put them in. They needed a different way to help the body.
Oral rehydration utilizes the sodium glucose transport system that is in the cells of the stomach and intestine, to get adequate fluids into the body.
We used to think that this system got water into the body by osmosis – the sodium and sugar got pumped into the body and the water followed.
Meinild has shown that this system is actually a water pump – one molecule of glucose, two of sodium, and 210 of water are actively pumped from the stomach into the blood stream, even against an osmotic gradient. That amount of fluid is every bit as good as an IV, and that amount of fluid is what was needed to treat the thousands of people dying with cholera.
With the rise of resistant bacteria, complications from anti-motility agents, and more recently from the antibiotics themselves which often compound problems, more physicians are promoting the use of oral rehydration as the first line treatment for diarrheal illness. In my practice it has been one of the most useful and effective ways of treating gastrointestinal disorders as well as keeping people well hydrated in the presence of any kind of illness. The British Medical Society said that oral rehydration may be one of the most significant medical advances of the last century.
In this country we have no category of "foods with drug effects" so anything, including a solution of sugar, salt and water, becomes a "drug" if it is intended to prevent or treat an illness. That is why most of us have never even heard of this sensible treatment, it is "grossly underused", and why "Pedialyte", the most common oral rehydration solution in this country, remains a food, without any label claims or treatment indications. There is now available a commercial product that matches the World Health Organizations recipe for oral rehydration available from Janias Brothers Packaging in Kansas City, Mo. The packet price is around $0.50 which is the same as the the WHO packets available throughout the world. They sell only by the carton so this is an item that your health food store or locally owed pharmacy is going to have to stock. Janias Brothers can be reached at (816) 421-2880. If you need help convincing your local supplier feel free to copy these pages and take it to them. Oral rehydration should be available to and on the shelf of every person in the country.
The following information has been among the most useful in helping people maintain good health in my practice. If you can't get someone to stock it for you this is an approximation that has worked well for me.
Who should use it?
Anyone who needs to replace fluids or who needs a little extra fluid because of illness, such as the fever discussed above. Definitely people with gastrointestinal losses should use this. That is what it is designed for. Whenever someone is ill an IV will usually make them feel better. This is an IV you can drink. Pregnant women with nausea and vomiting can usually tolerate this and it prevents the dehydration that is usually treated with an IV. Extra fluid is always helpful when one is dealing with infection – it helps the washing. I have even used this successfully with diabetics who are vomiting, but vomiting diabetics can have serious problems and should be in a hospital.
Would anyone not use it?
People with heart disease can get too much fluid and develop what is called congestive heart failure. Oral rehydration is not a good idea for them. If a person has an ulcer that is perforating the wall of their stomach they will have a whole lot of pain and their stomach will be rigid. Putting anything in a stomach with holes is not wise.
How is it made?
1 quart water,
3/4 teaspoon salt substitute (read the little print on the package, this should be mostly potassium chloride),
1/2 teaspoon baking soda, and
3 tablespoons white corn syrup (eg. Karo).
For other than babies this may be flavored with juice concentrate or unsweetened powdered drink mix such as Kool-Aid.
Important warning: measure the baking soda and salt substitute carefully to prevent imbalance problems.
How should it be used?
Some people chug-a-lug it, but this is not recommended. Best is to think of it as an IV and drink small amounts regularly. The journal Pediatrics in an article entitled "Vomiting and Diarrhea" recommends the following steps for infants that can easily be adapted upward for older people:
Step 1. Wait one hour after the last episode of vomiting.
Step 2. Give 1/2 oz. (15cc) to an infant or 1 oz. (30cc) to a child over one year old every 20 minutes for one to two hours. If an infant is being breast fed only two feedings of oral rehydration are all that is usually necessary.
Step 3. If vomiting does not recur, increase the amount gradually. The goal is to replace the fluids lost within six hours. If vomiting does return go back to step 1.
If you have gone through this cycle three times go to the doctor.
Step 4. Advance the diet and resume normal diet in 12 to 24 hours.
Pay attention to your body, don't force anything on it that doesn't feel right. When you are adequately hydrated your body will know.
Why use this?
In this day when we can stop diarrhea with a pill and calm and upset stomach with a shot why should one go through the turmoil? The best answer is to trust your immune system and try to support it in what it feels is best for your body. Some people whose diarrhea is caused by bacteria become carriers of those harmful bacteria when their diarrhea is stopped with medication. Some children have died of infection when they were given medicine that stopped their diarrhea. Trust your body.
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N Engl J Med 2000 Jun 29;342(26):1930-6
- The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections.
Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI
Children's Hospital and Regional Medical Center and the University of Washington School of Medicine, Seattle 98105, USA.
BACKGROUND: Children with gastrointestinal infections caused by Escherichia coli O157:H7 are at risk for the hemolytic-uremic syndrome. Whether antibiotics alter this risk is unknown. METHODS: We conducted a prospective cohort study of 71 children younger than 10 years of age who had diarrhea caused by E. coli O157:H7 to assess whether antibiotic treatment in these children affects the risk of the hemolytic-uremic syndrome and to assess the influence of confounding factors on this outcome. Estimates of relative risks were adjusted for possible confounding effects with the use of logistic-regression analysis. RESULTS: Among the 71 children, 9 (13 percent) received antibiotics and the hemolytic-uremic syndrome developed in 10 (14 percent). Five of these 10 children had received antibiotics. Factors significantly associated with the hemolytic-uremic syndrome were a higher initial white-cell count (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.5), evaluation with stool culture soon after the onset of illness (relative risk, 0.3; 95 percent confidence interval, 0.2 to 0.8), and treatment with antibiotics (relative risk, 14.3; 95 percent confidence interval, 2.9 to 70.7). The clinical and laboratory characteristics of the 9 children who received antibiotics and the 62 who did not receive antibiotics were similar. In a multivariate analysis that was adjusted for the initial white-cell count and the day of illness on which stool was obtained for culture, antibiotic administration remained a risk factor for the development of the hemolytic uremic syndrome (relative risk, 17.3; 95 percent confidence interval, 2.2 to 137). CONCLUSIONS: Antibiotic treatment of children with E. coli O157:H7 infection increases the risk of the hemolytic-uremic syndrome.
- N Engl J Med. 2000 Jun 29;342(26):1990-1
: J Physiol 1998 Apr 1;508 ( Pt 1):15-21
The human Na+-glucose cotransporter is a molecular water pump.
Meinild A, Klaerke DA, Loo DD, Wright EM, Zeuthen T
The Panum Institute, University of Copenhagen, Department of Medical Physiology, Blegdamsvej 3, DK-2200N Copenhagen, Denmark.
1. The human Na+-glucose cotransporter (hSGLT1) was expressed in Xenopus laevis oocytes. The transport activity, given by the Na+ current, was monitored as a clamp current and the concomitant flux of water followed optically as the change in oocyte volume. 2. When glucose was added to the bathing solution there was an abrupt increase in clamp current and an immediate swelling of the oocyte. The transmembrane transport of two Na+ ions and one sugar molecule was coupled, within the protein itself, to the influx of 210 water molecules. 3. This stoichiometry was constant and independent of the external parameters: Na+ concentrations, sugar concentrations, transmembrane voltages, temperature and osmotic gradients. 4. The cotransport of water occurred in the presence of adverse osmotic gradients. In accordance with the Gibbs equation, energy was transferred within the protein from the downhill fluxes of Na+ and sugar to the uphill transport of water, indicative of secondary active transport of water. 5. Unstirred layer effects were ruled out on the basis of experiments on oocytes treated with gramicidin or other ionophores. Na+ currents maintained by ionophores did not lead to any initial water movements. 6. The finding of a molecular water pump allows for new models of cellular water transport which include coupling between ion and water fluxes at the protein level; the hSGLT1 could account for almost half the daily reuptake of water from the small intestine.
Lancet 1978 Aug 5;2(8084):300-1
Water with sugar and salt.
Oral rehydration therapy for diarrhea: an example of reverse transfer of technology.
Pediatrics 1997 Nov;100(5):E10
Santosham M, Keenan EM, Tulloch J, Broun D, Glass R.
Johns Hopkins University, Center for American Indian and Alaskan Native Health, Baltimore, MD 21205, USA.
On November 13 and 14, 1996, a scientific symposium on oral rehydration therapy (ORT) was held at the Johns Hopkins University School of Hygiene and Public Health in Baltimore, MD. The purpose of the meeting was to review the current treatment practices for the treatment of this disease in the United States. The group noted that diarrhea resulted in 300 to 400 deaths per year among children, approximately 200 000 hospitalizations, 1.5 million outpatient visits, and costs >$1 billion in direct medical costs. ORT is well established therapy for the treatment and prevention of dehydration due to diarrhea. The principles of ORT treatment include early adequate rehydration therapy using an appropriate oral rehydration solution (ORS), replacement of ongoing fluid losses from vomiting and diarrhea with ORS, and frequent feeding of appropriate foods as soon as dehydration is corrected. The effective use of ORT has saved millions of lives around the world. However, in the United States, ORT is grossly underused. Contrary to the recommendations of the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC), health care providers overuse intravenous hydration, prolong rehydration, delay reintroduction of feeding, and inappropriately withhold ORT, especially with children who are vomiting. The expert panel noted that the majority of deaths, hospitalization, and visits to emergency departments could be prevented by the appropriate use of ORT. They generated guidelines for the treatment and prevention of dehydration secondary to diarrhea. These measures, together with training providers, could substantially reduce diarrhea mortality and decrease hospitalizations of children by 100 000 per year in the next 5 years.
Clin Infect Dis 1995 Oct;21(4):977-80
Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome?
Infectious Diseases, Veterans Affairs Medical Center, Boise, Idaho 83702, USA.
Anecdotal reports suggest an association between the use of nonsteroidal antiinflammatory drugs (NSAIDs) and the progression of invasive group A streptococcal infections to shock and multiorgan failure. There is a biochemical rationale that could support this theory. Though NSAIDs are frequently used to relieve pain or reduce fever, they also attenuate granulocyte functions such as chemotaxis, phagocytosis, and bacterial killing. In addition, findings in recent studies involving human volunteers injected with endotoxin suggest that pretreatment with NSAIDs enhances production of tumor necrosis factor, which leads to higher blood levels of this cytokine, probably by preventing feedback inhibition by prostaglandin E2. Thus, NSAIDs may contribute to the sudden onset of shock, organ failure, and aggressive infection by inhibiting neutrophil function, augmenting cytokine production, and attenuating the cardinal manifestations of inflammation.
Pediatrics. 1984 Nov;74(5 Pt 2):950-4.
Vomiting and diarrhea.
Vomiting and diarrhea are frequently encountered in pediatric patients. Dehydration, a serious consequence of both vomiting and diarrhea, results in the deaths of more than 700 children annually in the United States. With appropriate parent education, both morbidity and mortality can be reduced, and much of the anxiety about these problems can be alleviated. Parents must be educated to recognize the associated signs and symptoms that indicate serious disease and warrant notifying the physician. Fluid therapy should be individualized, and parents should be informed of the appropriate steps to take. Parents must make quantitative observations and keep records not only to enable the physician to assess adequate fluid balance but also to be able to demonstrate to themselves the effectiveness of the treatment. It is just as important for the physician to reassure parents, who will have concerns about long-term nutritional or growth consequences.