Suralimentation, called also "superalimentation," or "forced feeding," is based upon the theory that the best method to combat the symptoms of phthisis is by "stuffing " the patient with all the food which he can possibly digest. More food is needed than in health to counterbalance rapid tissue waste. The appetite is not always a reliable indication of the strength of the digestive organs, and, acting upon this fact, Debove introduced the plan of feeding by means of the oesophageal tube. It is only necessary to use this method when a patient loses all appetite, or acquires a positive disgust for food, and rapidly emaciates in consequence. The tube is employed in the manner described for feeding cases of insanity, and any form of desirable fluid food is introduced through it. It is sometimes only necessary to pass the tube to the level of the oesophagus, and the first few times that it is used it may be well to brush the pharynx with a two-per-cent solution of cocaine. The meals may be given three or four times a day, or a patient whose appetite is not wholly lost, but is inadequate, may prefer to eat part of his food himself and have other meals furnished through the tube.

The following are the foods most suitable for tube feeding: 1. Milk and its preparations; cream. 2. Raw eggs, eggnog. 3. Meat extracts, beef meal or powder. 4. Leguminous purees and cereals, thoroughly cooked and made fluid by predigestion with malt extract. A quart may be given at a time. If gastric catarrh is present the gavage should be preceded by lavage.

Debove, speaking of his method, says: "A patient who has no appetite, or who has a decided disgust for all food, will digest perfectly a large meal introduced by the tube, and even at the end of a certain time will recover appetite".

His method is first to wash out the stomach with cold water, and then pour in through the tube a litre of milk, one hundred grammes of fine meat powder, and an egg.

He adds that with suralimentation night sweats, cough, and expectoration are all reduced or disappear completely, while there is considerable gain in weight and strength and improvement in the physical signs in the chest.

Suralimentation may also be conducted without the stomach tube in patients who are able and willing to eat. They may be 32 given five or six meals a day. This applies to patients who are not having severe hectic fever, and in whom gastric catarrh is not a prominent symptom. Should vomiting occur during the treatment, it will be necessary to suspend it until the stomach is again in order. As a rule, in such instances it is better to discontinue medicines than food, if both are being taken. The presence of moderate fever - one or two degrees - is not in itself alone a contraindication for forced feeding, or for keeping the patient confined to bed. The gain of appetite which often accompanies removal to a favourable climate may be utilised to promote forced feeding.

The following diet recommended by Solis-Cohen serves as a good illustration of the proper regimen in the cases under discussion:

"Diet for Forced Feeding.

"The patient is to take a pint of hot water in the early morning to stimulate the stomach and cleanse it of mucus accumulated overnight.

"A half hour after the morning bath, milk punch and beef meal or peptonoids.

"Breakfast, a half hour later, consisting of rare steak or chop, eggs, sliced tomatoes, bread with plenty of butter, or cracked wheat and cream. In two hours, koumiss or soup, milk, bread and butter, celery salad, broth, and peptonoids.

Dinner, 1 P. M

Bouillon, rare beef, greens, Burgundy, beer, fruits.

3 Or 4 P. M

Koumiss, cream, or milk punch, peptonoids, malt extract.

7 P. M

Supper, like breakfast.

9 Or 10 P. M

Cream and cocoa or coca wine, milk, and peptonoids".

The patient should keep milk, or peptonoids, or some nutritious beverage by the bedside to be drunk if he awakens in the middle of the night.

Another diet well suited to some patients is thus outlined by Weber in his Croonian Lectures:

7 A. M

While still in bed, a cup of milk with a dessertspoonful of Cognac or lime water, or a cup of tea or cocoa, with bread and butter.

8.30 To 9 A. M

After dressing, milk and tea or coffee, bread and butter, fish, ham, or bacon.

11 A. M

Milk, koumiss, or broth, or a sandwich and glass of wine.

1 To 1.30 P. M

A substantial meal of meat, poultry, fish or game, fresh vegetables, a light pudding, fruit and a glass of wine.

4 P. M

Milk or koumiss, tea or coffee, with bread and butter or biscuit.

7 P. M

Another meal like that at 1 p. m.

9.30 To 10 P. M

A cup of milk, bread and milk, or milk or cream and farinaceous food, such as Hart's, Liebig's, Nestle's, or Mellin's. A glass of brandy if there are night sweats".

The question may properly be asked whether it is not possible to overfeed patients in this manner? This will happen when the increase in body weight exceeds the breathing capacity of the lungs - in other words, when the facilities for oxygen supply are disproportionate to the bulk of tissue to be supplied. The symptoms will be a coated tongue with dyspepsia and biliousness, increased pulse frequence, and possibly increased dyspnoea on exertion, all occurring without aggravation of the local physical signs. The food must then be reduced in amount. Both fluids and solids are to be restricted, and fish may replace meat temporarily.

Aids To Dietetic Treatment

It is not within the scope of this work to discuss the details of hygiene, but they should be at least mentioned as important adjuncts to dietetic treatment. In those cases especially in which forced feeding is recommended it is desirable to promote oxidation in every way. Patients should live in the open air all they can, sleep with the windows open, and, if possible, should go to a climate which enables them to be outdoors all day long. They should wear flannel undergarments, but should avoid dressing too warmly, and keep the feet warm and dry. Habits of moderate exercise, instruction in proper methods of breathing, cold bathing, massage, and reasonable mental diversion and good cheer are all useful factors in improving the digestion and assimilation of food. Worry and nervous strain of every kind should be avoided. Nine hours should be nightly allotted for sleep.

Of the long list of medicinal remedies which have from time to time won favour or notoriety for the treatment of tuberculosis, those which have best withstood the test of practical experience are the ones which, like creosote, act mainly by maintaining asepsis and preventing malfermentation in the alimentary canal. It is immaterial whether cod-liver oil be considered as a medicine or as a food. It has already been discussed as a food. In a negative way it should be stated that one of the best aids to digestion consists in preventing the patient from disordering the stomach and the appetite with all manner of cough mixtures and ill-advised tonics.

Such medicines as may from time to time be required for emergencies will be much better absorbed if the stomach has not been long kept in a state of dyspeptic irritability. In patients with constipation appetite and digestion will be improved by catharsis.