By subcutaneous alimentation is understood a method of nutrition by which nutriment is injected under the skin. In this way the alimentation is incorporated into the body without coming into contact with the digestive apparatus. This mode of nutrition has the great advantage that it is feasible with any lesion of the digestive tract, but it has the disadvantage that the alimentation escapes the action of every part of the digestive apparatus. As the entire process of nutrition takes place outside of the digestive tract, all the machinery which the organism possesses for the act of digestion is ignored. It is thus seen at a glance that this mode of nutrition is an unnatural one, and is to be employed only in extreme cases when every other method fails.
Subcutaneous alimentation was first introduced to the profession by Menzel and Perso,1 who experimentally injected solutions of milk and sugar subcutaneously into animals, and found that absorption took place. The same clinicians have also given oil subcutaneously to patients. Although this method of nutrition has been practiced off and on by Karst, Whitaker, Pick, Carter, and Koll, von Leube2 must be given credit for having improved and promulgated it. This great clinician noticed that injections of camphor oil were frequently given in various ailments without any detriment to the patient, and that oil could therefore be incorporated into the body subcutaneously without causing any obnoxious consequences. The same substance may therefore be used for nutritive purposes.
The question whether oil can be given in this way in sufficiently large amounts, and also whether it can be utilized by the organism, has been answered in the affirmative by von Leube and his pupils. They also found that,- while proteins, subcutaneously injected, cause without discomfort to the patient.
1 Arthur Menzel and H. Perso: Uber die Resorption von Nahrungs-mitteln vom Unter-hautzellgewebe aus. Wiener Med. Wochenschr, 1869, p 517.
2 Von Leube, W.: Über künstliche Ernährungs-tberapie. Bd.I,p.490, albuminuria, and solutions of sugar in high concentration cause various pains, - olive oil may be injected daily in amounts of 30 to 40 cc.
In employing this method, strict asepsis must be observed. Pure olive oil or sesame oil, previously sterilized, can be used.
The part of the body (preferably, the thigh) into which the injection is to be made, is first rubbed off with alcohol and then painted with iodine. A sterile glass syringe of about 15 to 20 cc, to which a thin rubber tube is attached, is connected with a canula having a large lumen. The syringe is filled with the oil at blood temperature, and is then attached to the canula, so that the oil drips out of the canula. The skin is then pierced with the latter, and the oil very slowly injected. Instead of a syringe, a funnel can be used, and the oil made to run in by its own gravity. The oil should never be injected too quickly. It is best to use ten to fifteen minutes for injecting 10 to 15 cc. of oil. On removing the canula, the wound is cleaned off with cotton and closed with iodoform collodion. Three such injections may be given daily.
Inasmuch as fat given as nourishment alone, without protein, increases the decomposition of the nitrogen content of the body, it is advisable when using this method of alimentation to also introduce some protein into the organism by some other way. Subcutaneous alimentation, therefore, will be used principally as a supplementary procedure, in connection with some other method of nutrition.
By rectal alimentation is understood the ingestion of nutritive material into the large bowel. Rectal alimentation is the oldest form of artificial (or extra-buccal) nutrition. This method was practiced as early as the middle ages, and the literature on this subject is quite extensive. We need mention only the names of Aetius, Hood, Steinhäuser, Flint, Ewald, Filippi, Albu, Leube, Bodenhamer, Stillman, Tyson, Rost, Aldor, Edsall and Miller, Eustis, Benedict, Adler, Gomp-ertz, Carter, and Goodall.
The nutritive value of this form of alimentation, especially with regard to protein and fat, has been found to be quite small. Beddard1 thought that the importance and value of rectal alimentation consisted chiefly in the amount of water introduced into the system. He says: "It is quite sure that more patients die on account of lack of water than from lack of nourishment. In all cases of rectal alimentation in which no water is given by mouth, physiological saline should be subcutaneously injected".
1 A. P. Beddard: Rectal Feeding. Guy's Hospital, October, 1901, p. 452.
Wernitz1 likewise laid stress on the importance of introducing more fluid into the body. He was the first to recommend rectal injections of saline by the drip method. He was convinced that by giving it slowly in this way the fluid is better absorbed. In this country, the rectal injection of physiological saline by the drip method has been promulgated by J. B. Murphy, of Chicago. Deucher, Eberhard, Strauss, Boas, and others, have likewise laid stress upon the injection of fluids, and also nutritive material, into the rectum slowly by the drip method.
During the period of rectal alimenation, the patient is best kept in bed. Before administering the feeding enema, a cleansing injection (consisting of a quart of 1 Wernitz, J.: Zur Behandlung der Sepsis. Correspondenzbl. f. Schweizerräzte, 1903, p. 41. 13 water and a teaspoonful of salt) should be given early in the morning, in order to thoroughly evacuate the bowel. One hour later, the first rectal alimentation may be administered. The feeding enema is best injected by means of a fountain syringe or a Davidson syringe, or a plain hard-rubber piston syringe, and a soft-rubber rectal tube which is introduced into the anus for a distance of about five to seven inches. The injection should be administered slowly and without much force. After the withdrawal of the tube from the rectum, the patient is told to lie quietly and to endeavor to retain the enema. The quantity of the feeding enema may be from five to ten ounces. From three to five such enemata may be given daily. All the material should be given at blood temperature.
Fig. 3 - Einhorn's rectal drip tube.
For the drip injections, it is best to have some warming apparatus for keeping the fluid at body temperature. Inasmuch as the rectal tube for the drip injection must be kept in the rectum for a long while, a very thin non-collapsible rubber tube of 8 to 10 F. (10 m.m. circumference) is recommended for this purpose. At the end of the tube there is a hard-rubber or metal capsule, provided with many openings (Fig. 3). This thin tube does not inconvenience the patient, and the capsule with the numerous openings facilitates the flow of the material.
Fig. 4. - Patient is being given saline by the Murphy drip method into the bowel.
The following substances may be used as feeding enemata:
The different kinds of peptones and propeptones in the market (Rud-isch's or Kemmerich's or Witte's peptone, somatose, sanose, sanatogen), of which about one to two ounces dissolved in from six to eight ounces of water are to be injected. The different beef juices (Valentine's beef juice, bovinine, Mosquera's beef jelly, etc.) may be dissolved in corresponding quantities.
Milk Enema, 250 to 500 c.c. of milk alone, or milk with the addition of half a gram of bicarbonate of soda.
These are the most commonly used. Their composition is as follows: six to seven ounces of milk, one or two raw eggs well beaten up in it, one teaspoonful of powdered sugar, and one-third of a teaspoonful of common table salt. Pancreatin (one tube of Fairchild's pancreatin) may be added to such an enema, to facilitate its assimilation.
Leube employs enemata consisting of well-chopped meat (five ounces), fresh pancreas (two ounces), one ounce of fat (butter), - all these ingredients being thoroughly mixed with about six ounces of water.
One ounce of grape sugar in ten ounces of water or physiological salt solution.
Instead of always using one and the same nourishing enema, the above combinations may be alternately administered.
In conjunction with these food enemata, injections of water into the bowel are made in order to increase the amount of fluid in the system. These injections of water for absorption are of great importance. They are retained much better if injected very slowly by the so-called "Murphy Drip Method." Usually saline or 5-6% glucose solution are employed, in quantities varying from a pint to a quart, which may be given twice a day.
The usual procedure is as follows:
7 a. m. : Cleansing enema.
8 a. m. : Egg-milk enema.
12 m. : Drip enema of 5 to 10 per cent grape-sugar solution, 500 cc. or more.
2 p. M.: Egg-milk enema. 6 p. m. : Egg-milk enema.
9 p. m.: Same as at 12 m.
Should the enemas cause diarrhea opium (tinctura opii, 5 drops) is added to the nutritive enema, and plain saline solution is substituted for the grape sugar solution.