ALIMENTATION IN PULMONARY DISEASE. BY ANDREW H. SMITH, M.D., Physician toYhe Presbyterian Hospital; Professor of Clinical Medicine at the New York Post-Graduate Medical School, New York City. Reprinted from the International Medical Magazine for August, 180 f ALIMENTATION IN PULMONARY DISEASE Alimentation plays a most important part in the management of dis- ease in general, but in pulmonary affections the problem is complicated by special conditions growing out of the functions of the affected organs. We are apt to regard nutrition too much as if it were only another term for digestion, and practically to assume that if the food taken into the stomach goes through the proper changes in the alimentary canal, and the nutritive portion is properly taken into the blood, this is all with which we need have any concern. But the truth is that all may go on perfectly well up to this point, and yet most serious defects in the nutritive process still be in store for the patient. The products of digestion when received into the circulation are not blood. They represent neither serum nor corpuscles; they are in fact dead matter, requiring to be vitalized by the process of assimilation before they become a part of the living blood. Of the manner in which this change takes place we know almost nothing. We even do not know in what organ or organs the corpuscles are formed. But we do know that an essential factor is the process of oxygenation that takes place in the lungs. This fact, which is amply attested by physiological observations, may be readily illustrated by any one in his own person. We all know how a few moments in the open air will increase the appetite for the morning meal, although the condition of the stomach is the same as it would have been if we had remained in the close atmosphere of the sleeping-room. In both cases the stomach is empty, but in one case the fresh air has thoroughly oxygenated the nutritive material in the blood derived from the meal of the previous evening, and in the other case a part of that material is circulating still in an unassimilated condition, and dulling the appetite as effectually as if it had remained in the stomach. For the desire for food is less an ex- pression of an empty stomach than of the absence of unassimilated material from the blood. It is not the completion of digestion so much as the completion of assimilation that is the signal for more food. It is the fact that the lungs are the seat of this essential part of the assimilative process that gives to pulmonary affections a peculiar relation to alimentation. For any considerable impairment of the action of the lungs cannot fail to impair at the same time the normal rate at which the crude 2 ANDREW H. SMITH, M.D. products of digestion are converted into living, active, life-sustaining blood. Material which has not undergone this change is for the time being not only useless to the economy, but a hinderance to proper metabolism. We see this illustrated in the hebetude and languor resulting from an insufficient supply of fresh air during digestion, and the prompt disappearance of these symp- toms when the blood is properly aerated. If, then, a considerable obstruction exists to the entrance of air into the lungs, it follows that an addition of more nutritive material to the blood than can be duly acted upon under the circumstances of crippled respiration, will only add to the circulatory embarrassment, and aggravate the condition of the patient. Under these conditions, therefore, we should study in acute cases to give as little nourishment as will sustain the vital powers rather than as much as the stomach can be made to digest. It is here that I believe a serious error is being constantly committed. In pneumonia, for example, the reac- tion from the excessive spoliation formerly in vogue, coinciding with an acute appreciation of the great nervous and muscular depression present in some cases, has led to an unreasoning effort to combat the disease by forcing food into the stomach. It is not long since the average hospital interne seemed to consider that his faithfulness to duty in a case of pneumonia was measured by the number of ounces of milk and beef-tea the unhappy patient could be made to swallow. To-day this idea is less prevalent, but it still has not entirely lost its force. We need constantly to remember that the extreme prostration so often seen in pneumonia is the result of a toxic infection of nerve and muscle, and that this toxaemia can no more be com- bated successfully by excessive feeding than if it were caused by the poison of a cobra or a rattlesnake. Efforts to " keep up the strength" by this means will result only in imposing a fresh burden upon the eliminating organs in getting rid of unassimilated material. If we turn from this type of pneumonia to that in which the peril lies in the excessive strain upon the right heart due to impediment in the pul- monary circulation, we shall find that here, too, only harm can result from crowding the vessels with more pabulum than can be acted upon in the gorged and paretic pulmonary circulation. The venous blood is dammed back in the lungs, and the right heart is forced to keep up a twofold struggle between the obstruction in front and the pressure from behind. It is in an evil case at best, but its plight may be made worse by adding to the mass it is required to move a quantity of material which cannot be made available for any useful purpose so long as the oxygenating function of the lungs remains in its crippled condition. But not less important than the quantity is the nature of the food. As the ultimate destiny of nutriment is to become tissue, that should be selected which requires least change to convert it into tissue. All forms of food are derived originally from the vegetable kingdom, but a large share of the work of converting vegetable material into our tissues may be done for us by ALIMENTATION IN PULMONARY DISEASE. 3 the lower animals. It is well to avail ourselves of this assistance when for any reason the conversion within our own economy is deficient or delayed. Flesh food is usually more readily digested than the carbo-hydrates, and the resulting peptones when taken into the blood are much more nearly allied to the tissues than are the sugar and other products that result from the digestion of vegetable substances. We shall therefore favor the chances of complete hsematosis if we select nitrogenous food. For the sake of greater ease of digestion it is better to give the nourishment in liquid form, and if given in small quantities, at short intervals, we shall avoid undue repletion both of the stomach and the vessels. When the patient is fully conscious, his sensations can be trusted as a guide to the amount of nutriment required, and food should never be forced upon him when his instinct rebels against it. Plain water, however, should be freely offered, and will often be gratefully accepted when liquid food would be refused, the instinctive feeling of the patient discriminating at once between what will keep the blood fluid and facilitate its circulation and what would act as a burden and a clog. If now we pass to chronic affections of the lungs, the same principle will hold good with certain important modifications in practice. We have here a chronic condition in which we are confronted with a restricted hsematosis on the one hand and urgent necessity for a high degree of nutri- tion on the other. The difficulty of reconciling these two conditions will be in proportion to the degree of lung insufficiency. How familiar is the picture of the flattened and motionless chest of advanced fibroid phthisis, with the accompanying complete anorexia, and the consequent bloodless face and white conjunctivae. There is no appetite,-not because of any faulty condition of the digestive organs, but because nutritive material taken into the blood continues to circulate in its crude and unassimilated form for lack of proper oxygenation, and its presence in this form excites a constant protest against a further ingestion of food. In the minor degrees of chronic lung insufficiency the respiratory move- ments make up in frequency what they lack in amplitude. So long as this compensation can be fully maintained, there may be no considerable defect in hsematosis, and, in the absence of fever, no marked failure of nutrition. But sooner or later a time comes when the respiration is so far impaired that enough oxygen cannot be taken into the blood to act upon such an amount of nutritive material as is necessary for the full maintenance of the economy. The moment this stage is reached, the appetite fails in propor- tion to the defect of hsematosis. This is in accordance with the conserva- tism of nature, and we should heed the warning. Unless we can improve the hsematosis, and with it the whole process of metabolism, we shall only do harm by high feeding. Digestion in these cases fails as well as assimi- lation, for the digestive fluids will be inefficient in proportion as the blood is poor from imperfect hsematosis. What can we expect from the peptic glands when they are supplied with a blood containing no more than half 4 ANDREW H. SMITH, M.D. the usual number of corpuscles and only twenty or thirty per cent, of haemoglobin? Moreover, in these chronic cases with pronounced anaemia and emaciation, we cannot rely chiefly upon nitrogenous food, as we must do in acute affections of the lungs. The heat-producing carbo-hydrates and fats are required in addition and these are more difficult of assimilation. Hence a vicious circle is established, the defective haematosis aggravating the dyspepsia, and this in turn resulting in greater poverty of the blood. Under these conditions life in the open air is of the utmost importance. Every atom of oxygen taken into the blood means a corresponding amount of assimilated pabulum for the tissues and better blood out of which to elaborate the digestive ferments. I have obtained much benefit in cases of this kind from rectal injections of defibrinated blood. This material seems to be absorbed almost un- changed, the corpuscles as well as the serum, it being a frequent experience that no trace of blood is found in the next dejection. There being no digestive action upon the blood, its absorption into the venous circulation is almost equivalent to transfusion very slowly performed; and but little change in the way of hsematosis is required to fit the added material for the immediate use of the tissues. This practice frequently results in a prompt improvement of the digestion, the gastric and intestinal glands being furnished with a richer blood, and yielding consequently a more efficient product. The benefit is sometimes very striking. I recall a case treated at the Presbyterian Hospital some years ago, in which the patient was so far gone with phthisis that I was surprised each day when I came into the ward and found his bed still occupied. There was an enormous cavity at the summit of the right lung; the patient was emaciated to the last degree, weighing only one hundred and one pounds the last time he had been able to stand on his feet to be weighed. He was extremely anaemic and took almost no food. He had been in the hospital since the 18th of August, and had gone down steadily in spite of all the usual restorative treatment. On November 5 the treatment with blood enemata was begun, four ounces being given each night at bedtime. After a few days the dose was reduced to two ounces. In two weeks he gained seven pounds. His appetite returned, and his digestion improved. He gained strength rapidly, and at the end of three months left the hospital at his own request, having gained thirty-three pounds, and considering himself well. The cavity in his lung had con- tracted greatly, and expectoration had nearly ceased. Other cases less striking than this, but still very remarkable, were re- ported to the Therapeutical Society in 1879, and published with the pro- ceedings of the Society in vol. xxix. of the New York Medical Journal. Though I prefer defibrinated blood for this purpose, for the reasons already given, yet good results may be obtained with the materials usually employed for rectal feeding, provided the patient can live much in the open air. I am convinced that rectal alimentation should enter largely into the in- ALIMENTATION IN PULMONARY DISEASE. 5 stitutional management of phthisis. In private practice it is difficult to carry it out, especially in its most effective form,-that is, with defibrinated blood. I have said nothing in regard to the use of alcohol as food. The sub- ject is too large to be entered upon on this occasion. I will only say that I have yet to be convinced that alcohol has not a nutritive value, if not directly, at least as aiding in the assimilation of other material. Clinically its usefulness seems to me more than as a simple stimulant. Both in acute and chronic pulmonary disease I believe that, carefully employed, it has a place that cannot be filled by any other agent. The quantity given need not be great, and if the odor of alcohol in the breath is persistent and very noticeable, it is a sign that the proper dosage is being exceeded. The foregoing is a necessarily brief and imperfect presentation of a subject the details of which would repay thorough consideration. International M < ILLUSTRATED MONTHLY /V1 F D 1 C A I devoted to MEDICAL AND SURGICAL 7\ /I SCIENCE. Magazine. EDITED, UNDER THE SUPERVISION OF JOHN ASHHURST, JR., M.D., AND JAS. T. WHITTAKER, M.D., LL.D., BY HENRY W. 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