CHAPTER XV

DISEASES OF THE RESPIRATORY TRACT

TUBERCULOSIS, PNEUMONIA, AND TONSILLITIS

TUBERCULOSIS

The dietetic treatment for tuberculosis must, as in any other pathological condition, depend largely upon the general condition of the patient, and the symptoms manifested at the time.

~Character of Disease.~--The disease may have reached an acute stage in which the rise of temperature is marked and the progress of the tuberculous symptoms rapid, or it may be found to be an old chronic condition in which the progress is slow.

Again, the patient may be found to be suffering from a tuberculosis which is neither acute nor very slow. Each of these stages requires slightly different treatment which, however, for the main part is much the same.

Individuals having an incipient form of tuberculosis have been known to develop an acute form of the disease upon being subjected to a strenuous treatment for some other and entirely different condition. This has been especially noticeable in certain individuals to whom the starvation treatment is given.

~Dietetic Treatment in Acute Stage.~--The dietetic treatment of the acute tuberculosis under such circumstances must necessarily be adapted to that of the original disease for which starvation was believed to be necessary. The forbidden foods must still be omitted from the dietary, but in these cases it is found advisable not to prolong the starvation treatment but to substitute foods which will do the least harm under the circumstances. This is necessary to cover the energy requirements of the body and to make good the tissue wasted through the development of the specific disease.

~Dietetic Treatment in Chronic Stage.~--The diet for tuberculosis has been so widely discussed and so universally used that a few words only seem necessary here. One of the chief points to be emphasized is the danger arising from gastro-intestinal disturbances. The digestive apparatus of the tuberculous individual is more apt to be impaired, so that any undue exertion required to digest a meal is likely to bring about disturbances more or less serious in character.

~Method of Administering Diet.~--For this reason it is no longer the custom to stuff the patient in an effort to overcome the inevitable tissue waste, since such treatment in many cases defeats the end for which it was intended, bringing on acute indigestion, or at times diarrhea, which might readily cause a greater loss of body weight than could possibly be produced by the surplus food given.

~Adjusting the Diet.~--More and more is it coming to be understood that the diet must be adjusted to suit the individual. Three wholesome meals a day are insisted upon, with lunches given between the morning and midday meal and during the course of the afternoon. Many patients are found to sleep better after they have partaken of a light lunch, consisting of hot milk, malted milk, or like beverages and crackers, so that this third meal is added to the other five. In this way the individual suffering with tuberculosis is assured of an efficient diet to meet the needs of the body without overburdening the digestive apparatus or overtaxing the excretory organs. The increased metabolism taking place in such patients, due both to the specific bacteria and to the febrile condition, is, as far as possible, provided for.

~Schedule of Diets.~--The following dietary regime may be useful in formulating menus for tubercular patients:

BREAKFAST

Fruits. 5 oz. cereals with cream. 1 or 2 eggs, simply prepared to prevent indigestion. 2 slices of bacon, ham; fish cake or chop. 2 slices of toast or crusty rolls with butter. Coffee, tea, or cocoa, with or without cream.[104]

LUNCH

Vegetable or cream soups. Cold meat, lamb chops, oysters, or fish. Baked white or sweet potato. 1 green vegetable,--greens, cabbage, spinach, or string beans. Stewed fruit or baked apple. Rice or tapioca pudding. Tea. Bread and butter.

At the end of the meal one glass containing two-thirds milk and one-third cream. If the latter disturbs the digestion reduce the amount temporarily, or add one-half the contents of a tube of peptonizing powder, or one-quarter of a glass of limewater.

DINNER

Meat, lamb, mutton, chicken, duck, game, or fish. Mashed or creamed potatoes. 1 or 2 green vegetables. Simple salads. Simple desserts consisting of puddings, custards, wine or fruit jellies, ices or ice cream, sponge cake or angel food cake.

The milk and cream is taken at the end of the meal as directed above.

LUNCHES

11 A.M., 4 P.M., 9 P.M., consisting of milk, malted milk, junket, buttermilk, albumenized broth, albumenized fruit juices, cream, egg, and vichy, eggnogs, served with crackers or sponge cake; cereal gruels and raw eggs taken with water, milk, or sherry may likewise form a part of this diet, since the nourishment in them is both concentrated and palatable.

~Use of Eggs.~--The old method of forcing the patient to eat a dozen or more raw eggs a day is no longer used, but three or four a day will be of undoubted value to the patient, provided they agree. There are patients, however, with whom eggs act almost as a poison, and in these cases it is decidedly unwise to force them.

~Use of Milk.~--Milk is to be used abundantly. If it should disagree, it may be peptonized or modified with limewater. At any rate, every effort should be made to enable the patient to drink at least one quart a day, and more, if possible.

If it fails to agree even when so treated, it should be abandoned, since the discomfort caused under the circumstances is more detrimental to the welfare of the individual than any benefit which he may gain by the small amount which may be absorbed.

~High Calorie Diet.~--As long as the patient is in bed the diet cannot be as full as it is made when he is up and about, as the body is then using more material to provide for the extra exertion and needs more food to replace that which has been utilized. Consequently the high calorie diet[105] will be found as a rule sufficient. As soon as the patient is able to receive more food without incurring digestional disturbances, it should be supplied, keeping ever in mind the danger of its upsetting his digestion.

~Advice to Patients.~--The patient must be impressed with the necessity for living a simple, wholesome life, free from excesses of all kinds. The need for a regular regime in the beginning must be strongly emphasized. Too strenuous exercise and the consequent over-fatigue at times completely overcome all the good which has been accomplished in weeks or even months of studied effort, so that rest is an essential part of the tuberculous regime. The patient should sleep from eight to ten hours out of every twenty-four, and if this sleep is taken in the open, that is, in a tent or on a sleeping porch, the benefits derived therefrom are inestimable.

~The Bowels.~--The bowels should move every day, even if some gentle laxative or an enema has to be used to bring about the desired result. In a majority of cases, mineral oil or bran muffins, prunes, raisins, and figs prepared with senna will be entirely sufficient, however, and these substances are much less harmful than drugs, for the habit of taking purgatives becomes a fixed one in a short time, and is especially liable to become so when the patient is forced, by reason of the sedentary life, to depend on some such measures.

~Massage.~--Massage has been found beneficial in many cases, giving the needed exercise to the body, which it is otherwise unable to obtain.

CHRONIC TUBERCULOSIS

In chronic tuberculosis, the patient should be instructed in the care necessary for his protection. He should be advised to report to the physician any symptoms occurring during the course of the disease, especially any hemorrhage. He must be reassured of the chances of recovery, even after hemorrhage has occurred. It is not well to encourage the habit of taking the temperature or weighing daily, since the knowledge of the fluctuations which inevitably occur in these conditions may worry the patient to such an extent as to interfere with his final recovery.

~Rest, Sleep, and Fresh Air.~--Moderation in physical exertion, wholesome food at regular intervals, plenty of rest and sleep, preferably in the open, and an effort made to look forward to a complete recovery will go far toward bringing about the desired result. The tuberculous patient who sets his mind on recovery, refusing to be discouraged by the numerous setbacks which may from time to time occur, has a much greater chance of living a long and useful life than the patient who makes no effort in this direction.

~Reenforcing the Diet.~--The following reenforced foods have been found valuable in the diet for tuberculosis, especially in those cases which are confined to bed and in which the effort to eat causes more or less gastric distress:

Milk, whole milk, milk and cream, milk diluted with Apollinaris water, peptonized, modified milk, reenforced with egg or egg white or reenforced with one to four tablespoonfuls of lactose, malted milk, buttermilk, cream, egg, and vichy, milk shake, milk punch, malted milk shake, chocolate or cocoa malted milk, albumenized fruit juices, egg and orange, egg and wine, reenforced, if desired, with lactose, albumenized broths, proprietary infant foods, such as Eskay's Food, Nestle's Food, Mellin's Food, Racahout, cream soups reenforced with lactose or egg, junkets, and ice cream.

PNEUMONIA

The diet in pneumonia is of considerable importance, since in this condition the strength of the patient is taxed by reason of the character of the disease, and the only means of attaining endurance to carry him through this trying period is by providing proper nourishment.

~Dietetic Treatment.~--The same general outline of diet is used as in acute infectious fevers, milk forming the basis of the diet. The patient is given an abundance of water and other beverages in addition to the other fluid foods to relieve the thirst which is so often a common symptom in this disease.

It is sometimes found advisable, however, on account of the vomiting which may occur, to give a more concentrated form of nourishment, in which case liquid peptonoids, trophonine, and panopepton furnish a form of nourishment which is both strengthening and stimulating in character, and for these reasons particularly desirable. Freidenwald and Ruhraeh advise against the use of starches and sugars in most cases of pneumonia.

~Daily Diet Schedule.~--The same fluid diets used in acute fevers and administered at two-hour intervals are advisable here. The following regime is used in pneumonia:

6 A.M. 6 oz. malted milk. 8 A.M. 6 oz. cocoa. 10 A.M. 4 oz. oatmeal or cornmeal gruel with 2 oz. cream. 12 M. 6 oz. chicken broth reenforced with 1 egg white. 2 P.M. 6 oz. malted milk chocolate. 4 P.M. 6 oz. albumenized orange juice. 6 P.M. 6 oz. chicken or beef broth, reenforced with egg white. 8 P.M. 6 oz. hot milk.

Night feeding consisting of milk, malted milk, or reenforced broth may be given at 12 M. and 4 A.M. if patient is awake.

The above diet may be varied by adding some of the beverages mentioned in the diet for tuberculosis or fevers.

~Convalescent Diet Schedule.~--As the acute symptoms subside and convalescence advances, the following diet may be instituted:

I

Breakfast 3 to 4 oz. cereal gruel with 2 oz. cream. 1 soft-cooked egg. 10:30 A.M. 6 oz. chicken broth, reenforced with egg, or 6 oz. albumenized orange or grape juice. 1 P.M. 6 oz. oyster soup with rolled crackers. 1/4 cup wine jelly with 1 tbs. cream. 1 glass (6 oz.) milk--2 parts milk, 1 part cream. 3 P.M. Milk shake (4 oz. milk, 1 egg white). Supper 4 oz. farina with 1 oz. cream. 6 oz. cocoa. 9 P.M. 6 oz. malted milk.

Hot milk, broth, or malted milk may be given during the night at 12 or 4 A.M. if patient is awake.

II

Breakfast 4 oz. orange juice on cracked ice. 3 or 4 oz. strained oatmeal with cream or butter. 1 slice soft toast. 6 oz. cocoa. 10 A.M. 1 soft-cooked egg on toast. 6 oz. milk. Dinner 6 oz. cream of celery soup. 2 oz. rice. 4 oz. custard (soft or baked). 6 oz. milk or cocoa. 3 P.M. 5 oz. cream, egg, and vichy. Supper 1 soft-cooked egg. 1 small baked potato. 6 oz. cocoa or malted milk.

III

Breakfast Stewed prunes. 3 or 4 oz. cream of wheat with 1 oz. cream. 1 soft-cooked egg. 1 slice of toast with butter. 6 oz. cocoa or milk. 10:30 A.M. Eggnog (1 egg, 4 oz. milk, 2 oz. cream, 1 tbs. whisky or sherry wine). Dinner Cream of spinach soup. 2 oz. mashed potatoes. 2 oz. green peas. 1 slice toast with butter. 2 oz. rice or tapioca custard. 3 P.M. 6 oz. albumenized fruit juice. Supper 1 slice toast. 1 poached egg. 6 oz. cocoa or hot milk. 2 or 3 oz. stewed fruit or prune whip.

The diet may be reenforced with lactose and meat added only when convalescence is well established.

~Tuberculosis Nursing.~--The nurse must keep in mind that the lungs are in a condition more or less out of commission, and their work of excretion is forced upon the kidneys. For this reason, as well as on account of the increased strain upon the heart, it is necessary to keep the diet light and avoid all foods which may in any way exert an unfavorable influence upon either the kidneys or the heart.

~Milk Diet.~--A strict milk diet has been found necessary in certain cases of pneumonia, but this is used only while the febrile condition lasts, after which the diet is gradually increased, as in the case of acute nephritis and in diseases of the heart, to meet the needs of the individual.

TONSILLITIS

~Dietetic Treatment.~--The diet in this condition is much the same as that used in other acute febrile conditions, that is, a fluid diet, the basis of which is, as a rule, milk.

The development of nephritis and certain cardiac symptoms at times follow attacks of tonsillitis, and for this reason the urine must be examined frequently and the diet carefully adjusted to avert, if possible, this danger. When acute nephritis does follow the attack of tonsillitis, the diet must necessarily be adjusted to meet that condition rather than that of the original disease.

~Special Diets.~--The Mosenthal diet, and at times the Karell Cure, is used with more or less success. This, however, is adjusted by the physician. It remains for the nurse to report any unfavorable symptoms as soon as they occur, and to carry out the line of dietetic treatment deemed advisable by the physician.

SUMMARY

TUBERCULOSIS

~Form.~--Acute and chronic in character. The chief aim of the treatment in the former is to prevent its development into a chronic form.

~Rest.~--~Sleep~, preferably in the open air, in a tent or on a sleeping porch.

~Proper Surroundings~ should be striven for. The patient should be kept tranquil in mind and body, free from disturbing worries and assured of the possibility of recovery with proper care.

~Diet~ should be adequate without being too abundant; stuffing the patient is no longer considered necessary, in fact it is believed that forcing the eating of large quantities of eggs, etc., defeats its own ends, upsetting the digestion and causing a disgust for food almost impossible to overcome.

~Gastro-intestinal Disturbances~ are apt to develop as the disease progresses. These are treated as in other conditions so complicated, except that the period of starvation must necessarily be limited on account of the metabolic waste already taking place from the disease itself.

PNEUMONIA

~The Lungs~, as in pulmonary tuberculosis, are the seat of infection and are temporarily hampered in their work of excretion.

~The Kidneys~ bear the brunt of the extra work caused by the impairment of the lungs, consequently all unnecessary work must be spared these organs if they are to be prevented from being overtaxed.

~Nephritis~ is one of the complications apt to develop when the kidneys are not sufficiently strong to carry on their own work and that generally done by the lungs.

~The Heart.~--Cardiac symptoms are also likely to develop during attacks of pneumonia and make the disease one to be dreaded and guarded against.

~The Diet.~--The dietetic treatment in pneumonia is like that used in acute infectious diseases, fevers in general, fluids constituting the form of diet and milk the chief food, as long as there is an elevation of temperature.

TONSILLITIS

~The Heart.~--As in pneumonia, the development of cardiac symptoms must be guarded against. These symptoms may not develop at once but show later during or after convalescence.

~The Kidneys.~--Nephritis also develops in some patients and the treatment is directed as far as possible to prevent its developing into a chronic form.

~Dietetic Treatment~ is the same as used in acute infectious conditions, fevers of short duration, taking care to institute the diet for acute nephritis should the patient show evidences of this disease.

PROBLEM

Write a diet order for a tuberculous patient weighing 135 pounds, allowing 3000 calories and fifty per cent. of the protein to be derived from animal sources.

FOOTNOTES:

[104] The addition of cream to coffee produces acute indigestion in certain individuals, hence the nurse must be governed by this point in formulating the diet.

[105] See "High Calorie Diet for Typhoid Fever," Chapter XIV.