|
The following facts on the value of emaciation, from the Lancet of Sept. 27, are of interest. Emaciation is a prominent feature in many diseases. Many of the phenomena of disease are, in reality, efforts at repair. It will therefore be advantageous to inquire if some good purpose is not served by emaciation. To begin with diseases which affect the circulation, in many such we may note that the patient will rapidly lose flesh, and that when the loss has proceeded to a certain degree it is arrested. The patient becomes and continues thin. Not only is it difficult to fatten him, but he is not much benefited by the attempt. Should his disease be arrested, but leave some injury behind, the patient will probably continue thin. Instinctively, in consequence, we look for the presence of disease, active or quiescent, in sparely developed persons ; and practically we look for it in the territory of the circulation, either pulmonary or systemic, and generally find something. Such emaciation, ceasing at a certain point, does not much exceed what is seen in athletic training, and may be defined as an involuntary training, forced upon the patient by his ailment.
What, briefly, is the benefit of training? Unusual effort in untrained men or animals is checked, not by muscular exhaustion, but by congestion of the pulmonary circulation, and paralysis of the right ventricle of the heart. The effect of training is to enable the pulmonary circulation to keep pace with the increased activity of the systemic. Several changes concur to this end,-dilatation of the lung and of its blood-vessels, hypertrophy of the right side of the heart, and most especially absorption of every tissue which is found to be superfluous for the effort in view. This absorption reduces the area of the systemic circulation; and it is followed by a reduction in the quantity of blood, because a smaller quantity will suffice for active circulation through the lesser area. The individual so trained is in the condition of having a pulmonary territory larger than is necessary for his state of rest, and consequently with a greater margin for relief upon exertion. Conversely, the contrary condition of obesity develops the systemic circulation to the full capacity of the lungs, so that the least exertion will produce dyspnoea. Acute disease being like exertion, we can see the advantage of entering upon it in a state of training. The exhaustion to be feared is that of the heart's right ventricle; and the inconvenience of existing stimulants is, that they do not stimulate the right ventricle by itself.
To return to emaciation as produced by disease. Let us first take the case of diseases of the lung. Should the territory of the pulmonary circulation be diminished by' such a disease as phthisis, it would be impossible for the patient, without emaciation, to have an active circulation in the systemic area without danger of congestion of the lung. The feeble attempts that are made at hypertrophy of the lung in this disease are thus met half way. The same thing is true of all emphysema of the lungs, whether senile or morbid. Then we may consider the disorders of the greater circulation. In disease of the valves, when the muscle has to do the work of the valves, and in decay of the aorta, when the ventricle has to combine the aorta's duty with its own, the smaller the volume of blood to be dealt with, the better. Without reduction of the area through which it flows, a reduced amount of blood would only result in a sluggish circulation. Emaciation in such cases is therefore salutary. Moreover, the capillaries are the seat of greatest friction : they are therefore the part to be reduced. This is the reason why all animals, in a state of nature, grow thin as they grow old. Man, and the creatures under his control, may violate this law, but not with impunity. Acute disease, when the arteries are decayed, is doubly dangerous. The right ventricle of the heart may be exhausted, as before, but now the left ventricle may also prove unequal. Stimulants here can have but little drawback; but in surplus lung, and an amount of blood that is well within the powers of propulsion, lies a greater safety. Obesity is dangerous to the aged.
It would be well to consider the phenomena of waste in fever by the light of an assumption that they are salutary. The brute creation, when suffering from fever, eat nothing; yet they do not die, but recover. The body seems destined to feed upon itself, and to delay all repair until convalescence. Great responsibility rests upon those who supersede this instinct by an artificial method. Graves, who fed fevers, at the same time bled his patients. Venesection has this drawback, that to relieve the right heart we are obliged to stint the left, and to reduce the systemic circulation to a sluggish flow. The speedy repair of such loss of blood shows that its benefit must be only temporary. Such a remedy is an imperfect substitute for a capacious lung. The perception of this inconvenience has led to the disuse of bleeding. The concomitant pressing of food in fevers should probably follow it. The most evident of natural remedies for any kind of fever are starvation and emaciation. However indulgent appetite may be in health, it returns in disease to the strictest authority, Obedience to its dictates may shatter superstitions, but will not jeopardize the cure. In chronic diseases, the physician who thinks of the future of his patient will look grudgingly on fat. It provides for warmth and irregularity of nutrition. If these be provided for in other ways, much relief can be given to the circulation; and if in acute disease the presence of a tissue should prove an embarrassment, the physician will not interfere with its removal.
This article was originally published in Science (Nov. 7, 1890).
|
|
