Medical Nutrition Therapy A Case Study

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 6-1

Answer Guide for Medical Nutrition Therapy: A Case Study Approach 5th ed.
Case 6 – Heart Failure with Resulting Cardiac Cachexia
I. Understanding the Disease and Pathophysiology

1. Outline the typical pathophysiology of heart failure. Onset of heart failure usually can be traced to damage
from an MI and atherosclerosis. Is this consistent with Mrs. Maney's history?

• Many different events can lead to the development of congestive heart failure.
• Previous myocardial infarction, valve defect, or increased work demand on the heart from other conditions
such as hypertension all can damage the heart.
• This damage results in a decreased ability of the heart to pump adequately.
• When there is reduced blood flow to tissues, the body compensates in several ways.
• The kidney responds to decreased blood flow by secreting renin and aldosterone, causing
vasoconstriction and an increase in blood volume.
• The heart then has to work even harder to handle the increased blood volume.
• Over time, the heart enlarges (cardiomegaly) with its attempt to handle the increased workload.
• Cardiac output and stroke volume decrease.
• Compensation mechanisms do work for a time but eventually the heart muscle weakens.
• Dr. Maney’s medical history is consistent with the typical pathophysiology of heart failure. She has a long
history of coronary artery disease, hypertension, and mitral valve disorder. She also experienced a
myocardial infarction. Her previous medical diagnoses are all indicative of damage to the heart muscle,
which is the first step in the progression of heart failure.

2. Identify specific signs and symptoms in the patient’s physical examination that are consistent with heart
failure. For any three of these signs and symptoms, write a brief discussion that connects them to
physiological changes that you described in question #1.

• Jugular venous distention

• Ascites
• 2+ pedal edema
• Shortness of breath
• Increased pulse (110) respirations (24), lower blood pressure (90/70)
• Rales
• Skin - gray
a) Rales
Due to decreased cardiac output and the resulting low blood pressure present in HF, the RAAS is
activated by the kidneys. This system attempts to raise blood pressure by increasing sodium and water
retention. Fluid accumulates in the pulmonary vein and backs up into pulmonary circulation, which
increases pressure in the pulmonary capillaries. This increased pressure pushes fluid into the lungs, causing
pulmonary congestion/edema. The presence of fluid in the lungs can be heard through a stethoscope as
rales or crackles as the air tries to move through the fluid with each breath. Because the system lacks the
oncotic pressure to pull the fluid back into the capillaries, it continues to accumulate in the lungs, leading to
labored breathing and dyspnea. This, in turn, leads to tachypnea, as the patient must breathe more rapidly to
get enough oxygen into the lungs.
b) 2+ pedal edema
As the heart enters right-sided HF, it remains unable to pump blood efficiently. The right side of
the heart cannot maintain cardiac output, so blood volume decreases. The decrease in renal blood flow
again activates the RAAS to increase sodium and water retention, which then causes fluid to back up into
the systemic circulation.5 This increased venous pressure in the systemic circulation causes fluid to leak
from the capillaries into the third spaces near the ankles and feet (largely due to gravity) leading to pedal
edema. Again, the heart is not strong enough and the vessels lack the oncotic pressure needed to pull the
fluid back into circulation, so it continues to accumulate, increasing the severity of the edema.
6-2

c) Tachycardia
As the failing heart works to increase cardiac output to normal levels, it must beat harder and faster to
do so. The release of hormones by the sympathetic nervous system not only cause vasoconstriction and
activation of the RAAS, but also increase the heart rate and contractility.

3. Heart failure is often described as R-sided failure or L-sided failure. What is the difference? How are the
clinical manifestations different?

Heart failure can involve the left side, the right side, or both sides. However, it most often begins with the left
ventricle. In left-sided HF, the left side of the heart experiences dysfunction and is unable to adequately maintain
cardiac output. In right-sided HF, the right side of the heart cannot maintain cardiac output. Because the left and
right sides of the heart have different functions, the resulting signs and symptoms caused by their failure are
different. Though initial compensation by the body occurs, it cannot be maintained, and one-sided HF often expands
to the entire heart, leading to decompensated HF.
Left-sided HF is typically the result of end-stage CAD or MI. When the left ventricle is damaged, it becomes
weakened and cannot pump blood adequately to the systemic circulation. This can be further classified as systolic or
diastolic. In systolic left-sided HF, the left ventricle has diminished contractility and cannot fully empty. In diastolic
left-sided HF, the left ventricle experiences impaired relaxation and is unable to fill completely. Both of these
situations lead to a decreased cardiac output and a resulting activation of the RAAS system in order to restore blood
volume by increasing sodium and water reabsorption by the kidneys. The increase in fluid causes a backup of blood
into the pulmonary circulation. The excess fluid in the pulmonary vein causes an increase in pressure in the
pulmonary capillaries, and fluid is forced out of the vessels and into the lungs. This fluid makes it difficult to
breathe, leading to dyspnea and tachypnea. Because the blood vessels lack the oncotic pressure to pull the fluid back
out of the lungs, blood pressure remains low, and the system continues to stimulate the RAAS system to try to bring
the body back to homeostasis. This leads to additional fluid accumulation and further pulmonary congestion.
Right-sided HF is most often the result of left-sided HF.3 When the right side of the heart begins to fail, it
cannot maintain cardiac output to the pulmonary trunk. Again, the RAAS system is stimulated to retain sodium and
water. This causes blood to back up into the systemic circulation. The high pressure in the periphery causes fluid to
leak out into the third spaces near the feet and ankles as well as the liver and abdominal organs, resulting in pedal
edema and ascites as well as splenomegaly and hepatomegaly. Additionally, venous pressure remains high, which
results in the distention of the jugular vein in the neck and cerebral edema, which causes headache.
Both left- and right-sided HF lead to fatigue, dyspnea, and generalized weakness. Furthermore, the presence of
edema in the abdominal region and dyspnea together cause a decrease in appetite/increase in satiety. This has
many nutritional implications, including malnutrition and cardiac cachexia.

II. Understanding the Nutrition Therapy

4. Mrs. Maney’s husband states that they have monitored their salt intake for several years. What is the role of
sodium restriction in the treatment of heart failure? What level of sodium restriction is recommended for the
outpatient with heart failure? What difficulties may a patient have in following a sodium restriction?

• Some level of sodium restriction is necessary in the treatment of heart failure because of the complications
associated with severe fluid retention. Sodium in the body attracts fluid, meaning that an excess of sodium
from the diet will cause additional fluid retention. Excessive fluid retention causes peripheral edema,
ascites, and pulmonary congestion in heart failure patients. The clinical manifestations of fluid overload
can increase the patients' energy expenditure (increased work of breathing/respiration rate), while causing
eating difficulties (dyspnea, ascites pressing against the stomach). It is essential that these patients control
their intake of sodium, which in turn controls their level of fluid retention.
• A 2,000 mg sodium diet is a standard initial recommendation.
• Adjustments to levels of 1,000 mg or 500 mg may be prescribed depending on an individual patient’s
medical condition—specifically, fluid and volume states as well as overall oral intake.
• These levels of sodium restriction are a challenge to manage outside a hospitalized setting, so it is critical to
evaluate the patient’s actual PO intake to determine the level of sodium the patient is consuming prior to
putting any further modifications in place. However, in malnourished or cachectic patients who have
 6-3

anorexia, caution should be exercised. This is because the first priority in the HF patient is to ensure they
are getting enough nutrients to maintain weight and support healing.
• Such difficulties include: sodium's high prevalence in Western/processed foods, salt's prominent role in
flavor/taste, and salt's high use in foods at restaurants

5. Why is Mrs. Maney placed on fluid restriction? How will this assist with the treatment of her heart failure?
What specific foods are typically "counted" as a fluid?

• On admission she was had fluid retention and had prerenal azotemia.
• Physical exam reveals 2+ pedal edema that demonstrates her fluid overload
• The patient’s creatinine and BUN are also elevated.
• These findings are compatible with low kidney perfusion.
• Fluid restriction will improve clinical symptoms and quality of life.
• Foods “counted” as fluid: All beverages (including water, milk, juices, coffee, tea, soft drinks),soups,
gelatins, fruit ice, Popsicles™, liquid nutritional supplements, ice cream, puddings, custard, sherbet, ice,
soups, and anything liquid (or that melts) at room temperature.

6. Identify any common nutrient deficiencies found in patients with heart failure.

Common nutrient deficiencies found in patients with heart failure include: potassium, magnesium, thiamin,
riboflavin, pyridoxine, folate, B-12, calcium, and zinc. Many of these nutrient deficiencies are caused by drug-
nutrient interactions. A common drug-nutrient interaction in heart failure patients is the loss of water-soluble
nutrients when a combination of multiple diuretics is used to remove excess fluid from the body. Sdditional
research is being done to determine the appropriate use of some supplements, such as omega-3 fatty acids and
coenzyme Q10, in HF patients. While results do not suggest any strong evidence for the supplementation of
either of these substances, there remains a possibility that they may help the HF patient. L-arginine and
carnitine are also being investigated for potential supplementation.

III. Nutrition Assessment

7. Identify factors that would affect interpretation of Mrs. Maney’s weight and body composition. Look at the
I/O record. What will likely happen to Mrs. Maney's weight if this trend continues?

• Ascites and peripheral edema

• Mrs. Maney’s I/O record shows an overall net fluid retention of 408 mL over a 24-hour period since her
admission. If this trend continues, Mrs. Maney’s measured weight will increase to reflect additional fluid
retention. A negative net I/O value would correlate with a decrease in measured weight.
Mrs. Maney also has signs of muscle wasting (temporal wasting and weak handgrip) which may indicate a
loss of lean body mass. These may be masked due to fluid retention.

8. Calculate Mrs. Maney’s energy and protein requirements. Explain your rationale for the weight you have
used in your calculation.

• Mrs. Maney’s IBW (50 kg) is used for calculations as her current weight is masked by fluid retention. This
is within 10% of her current weight.
• Energy: energy needs for cardiac cachexia may be calculated using the American Chest Physician’s
nomogram. 50 x 25 = 1250 kcal 50 x 35= 1750 kcal Range: 1250-1750 kcal

• Protein: AND EAL recommends 1.37 g/kg for heart failure patients.
47.7 kg × 1.37 = 65 g/day

9. Do you have any evidence that Mrs. Maney may be malnourished? Identify factors that may support a
diagnosis of malnutrition using the latest AND/ASPEN proposed guidelines for malnutrition diagnosis.
• Yes, there is evidence that Mrs. Maney is malnourished
• Muscle loss at her temporal region
6-4

• Fluid accumulation is present: ascites, 2+ pedal edema (though, her heart failure complicates this clinical
evidence for malnutrition) and would be difficult to interpret.
• Weak grip strength
• < 27% energy intake (per 2 cans of Boost daily)

10. Malnutrition in heart failure is often referred to as cardiac cachexia. What is cardiac cachexia? What are
the characteristic symptoms? Explain the role of the underlying heart disease in the development of
malnutrition.
• Cardiac cachexia is a wasting syndrome caused by heart failure that results in a metabolic imbalance
favoring catabolism over anabolism. Losses in lean and fat tissue, in addition to bone mineral density, can
be observed and is not always reversible upon feeding (like starvation).
• Signs and symptoms: increased plasma TNF-α, decreased GI tract perfusion (slowed peristalsis, early
satiety, and impaired nutrition absorption), and endothelial dysfunction (leading to a reduction in skeletal
muscle nutrient supply).
• Heart failure promotes the development of malnutrition through inflammatory pathways, elevated levels of
B-type and atrial natriuretic peptides, aldosterone, and cortisol, and anorexia.

11. Do you feel that Mrs. Maney may benefit from enteral feeding? What guidelines would you use to make this
decision? Outline a nutrition therapy regimen for her that includes formula choice, total volume, and goal
rate.

• Yes, Mrs. Maney would benefit from enteral feeding since she is consuming < 5% of her meals and
consumed < 27% of her energy needs prior to admission
• ASPEN guidelines should be used to make this decision; since she is malnourished and critically ill at
admission
• Formula choice: Two-Cal HN (high-protein formula that provides 2 kcal/mL) = 1800 kcal
• Total volume: 900 mL
• Goal rate: 38 mL/hr
• Osmolality of Two-Cal NH is 725 mOsm/kg H2O; therefore, the initial rate should be 20 mL/hr for first 8
hours, then advanced 10 mL/hr every 4 hours until goal rate is reached.

12. Identify any abnormal biochemical values associated with Mrs. Maney's heart failure or CVD and assess
them using the following table:

Name of Normal Patient’s Reason for Abnormality

Laboratory Value Value Value &
Date
Sodium (mEq/L) 136-145 132 (2/14) Fluid overload resulting in dilution of serum sodium
133 (2/16)
135 (2/20)
BUN (mg/dL) 6-20 32 (2/14) Decreased renal perfusion; Cardiac cachexia (protein
34 (2/16) catabolism, muscle wasting)
30 (2/20)
Creatinine serum 0.6-1.1 1.6 (2/14) Decreased renal perfusion; Cardiac cachexia (protein
(mg/dL) 1.7 (2/16) catabolism, muscle wasting)
1.5 (2/20)
 6-5

Name of Normal Patient’s Reason for Abnormality

Laboratory Value Value Value &
Date
Bilirubin, direct <0.3 1.0 (2/14) Abnormal liver function; hepatomegaly resulting from edema in
(mg/dL) 1.1 (2/16) liver
0.9 (2/20)
Protein, total (g/dL) 6-7.8 5.8 (2/14) Fluid overload resulting in dilution of serum protein
5.6 (2/16)
5.5 (2/20)
Albumin (g/dL) 3.5-5.5 2.8 (2/14) Fluid overload resulting in dilution of serum albumin; increased
2.7 (2/16) protein catabolism due to cardiac cachexia
2.6 (2/20)
Prealbumin 18-35 15 (2/14) Fluid overload resulting in dilution of serum prealbumin;
(mg/dL) 11 (2/16) malnutrition (cardiac cachexia); possible abnormal liver
10 (2/20) function (hepatomegaly)
ALT (U/L) 4-36 100 (2/14) Impaired liver function resulting from edema in liver
120 (2/16) (hepatomegaly); Damage to heart muscle;
115 (2/20)
AST (U/L) 0-35 70 (2/14) Impaired liver function resulting from edema in liver
80 (2/16) (hepatomegaly) Damage to heart muscle;
85 (2/20)
CPK (U/L) 30-135 180 (2/14) Damage to heart muscle;
200 (2/16)
205 (2/20)
Troponin T (ng/L) <0.03 0.035 Past cardiac injury (myocardial infarction)
(2/14)
0.037
(2/16)
0.036
(2/20)
Troponin I (ng/L) < 0.2 0.026 Past cardiac injury (myocardial infarction)
(2/14)
0.028
(2/16)
0.027
(2/20)
HDL-C (mg/dL) >59 30 (2/14) History of coronary artery disease; genetic, lifestyle and diet
31 (2/16) may contribute.
30 (2/20)
LDL (mg/dL) <130 180 (2/14) History of coronary artery disease; genetic, lifestyle and diet
160 (2/16) may contribute.
152 (2/20)
LDL/HDL ratio <3.22 5 (2/14) History of coronary artery disease; genetic, lifestyle and diet
5.23 (2/16) may contribute.
4.97 (2/20)
WBC (× 103/mm3) 4.8-11.8 12 Inflammation and overall disease state
12
10.5

13. The following drugs/supplements that were prescribed for Mrs. Maney. Give the medical rationale for the
use of each. In addition, describe any nutritional concerns for Mrs. Maney while she is taking these
medications.

Medication Rationale for Use Nutrition Implications

6-6

Medication Rationale for Use Nutrition Implications

Lanoxin Increases myocardial
contraction.
Lasix Diuretic used in edematous
states to improve fluid
balance; sometimes used to
lower blood pressure.
Dopamine Increases myocardial
contraction and has a pressor
effect to help support blood
pressure when low.
Thiamin Diuretic use can lead to
thiamin deficiency.
Side effects of this medication include diarrhea, loss of
appetite, stomach pain, nausea, and vomiting; all of these
side effects can make eating difficult and unpleasant,
resulting in suboptimal oral food and nutrient intakes.
Avoid avocado, high fiber foods within 2 hours of taking
medication, limit sodium, avoid milk, Ca supplements, iron,
antacids or aluminum salts 2 hours before or 6 hours after
taking medication. Avoid K containing salt substitutes, limit
garlic, ginger, gingko, and horse chestnut
Hypokalemia, hypomagnesemia, thiamin deficiency,
calcium deficiency; supplementation may be necessary
depending of severity of electrolyte or nutrient deficiency.
Side effects include potential decrease in serum potassium,
proteinuria, nausea, and vomiting; may require potassium
supplementation or high-potassium diet choices; nausea and
vomiting may inhibit adequate caloric intake.
NA

IV. Nutrition Diagnosis

14. Select two nutrition problems and complete a PES statement for each.
• Inadequate oral food/beverage intake related to poor appetite as evidenced by few sips of liquids, soft
foods, and “trying to take Ensure.”
• Inadequate intake from enteral nutrition related to intolerance secondary to uncontrolled diarrhea as
evidenced by ___ (more data would be needed regarding the specific amount that was either provided or
withheld during this period of time, e.g. “only X mL of formula compared to goal rate”).
• Malnutrition related to anorexia and SOB as evidenced by consumption of <75% of estimated energy
needs, moderate temporal wasting and reduced handgrip strength.

V. Nutrition Intervention

15. Mrs. Maney was not able to tolerate the enteral feeding because of nursing report for diarrhea. What
recommendations could be made to improve tolerance to the tube feeding?

• The formula could be changed to one with added fiber (such as Jevity) or fiber could be added to Mrs.
Maney's medications.
• It is important to remember that fiber supplements should not be added separately to the enteral formula or
placed down the feeding tube. It may cause interactions with the formula and could result in a tube
blockage.
• Additionally, an antidiarrheal agent such as loperamide could be used.
• Depending the osmolality of the formula, it may be advisable to have a lower initiation rate to lower the
"water-pulling" effect that the higher osmolar formula may have in the intestinal tract.

16. The tube feeding was discontinued because of continued intolerance. Parenteral nutrition was not initiated.
What recommendations could you make to optimize Mrs. Maney's oral intake?

• If she is able to eat, provide her with foods that she likes with increased nutrient density.
• Small, frequent feedings work well to minimize the volume of food consumed and stress on both the
cardiac and respiratory systems.
• Within her fluid allowance, use of a nutrient-dense liquid supplement may be easier than attempting to
consume solid food.
 6-7

• Consume fluids between meals to prevent their contribution to fullness during mealtime

17. Outline steps you would take to assist Mrs. Maney as she prepares for discharge. Include the specific
nutrition education that you would include.
• Assess readiness/motivation for change
• Educate the importance of sodium and fluid restriction and their implications on the clinical manifestations
and exacerbations of her cachexic state (increased work of breathing due to pulmonary congestion,
anorexia, etc.)
• Educate Mrs. Maney on nutrient density – steps to add both kcal and protein to her diet. Suggest that Mrs,
Maney have assistance with meal preparation and grocery shopping. Attempt to get at least 1/3 of her kcal
at the meal where she is hungriest. Could also suggest spreading meals over 5-6 small feedings rather than
only three. Discuss the use of high calore and high protein supplements. Every bite of food should provide
both kcal and protein –discourage consumption of empty calorie foods.
• Educate Mrs. Maney on fluids:
o See question 5. for examples
o How to optimize/reduce intake (e.g. avoid salty foods, drink only when thirsty, etc.)
• Educate on low-sodium and avoidance of high-sodium options:
o Low sodium: fresh or frozen vegetables, fruits, unprocessed meats, noodles, rice, English muffins,
etc.
o High-sodium: processed foods, salty snack foods, soups, sauces, fast foods, pickles, etc.
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 Nous franchissons deux portes voûtées et bastionnées, et nous
voici en ville. C’est d’abord une place, ou mieux une cour de
forteresse entourée de bâtiments militaires auxquels des galeries
extérieures, à chaque étage, enlèvent le caractère de tristesse et de
nudité particulier à l’architecture des casernes. Des soldats font
l’exercice, et de tous points éclatent des commandements, des
coups de clairon, des roulements de tambour.
On débouche dans une rue étroite, l’artère principale, Main
Street, qui suit le rocher jusqu’à la pointe d’Europe. Des ruelles
tortueuses escaladent, à gauche, les premiers contreforts et
s’arrêtent brusquement, barrées par le roc, tandis qu’à droite, elles
sont coupées par les bâtiments militaires et les ouvrages de
défense.
En une double ligne de magasins, d’entrepôts, de boutiques
gorgés de marchandises et de denrées anglaises se presse une
population étrange :
Espagnols, Marocains, Grecs, Arabes, juifs de Tanger, nègres,
Allemands, malandrins de toutes les races, « tous gens, dit Richard
Ford, qui se sont expatriés pour le bien de leur pays ». Oh ! la
curieuse foule et la belle collection de coquins ! Je retrouve la ville
algérienne d’il y a vingt-cinq ans, avec son peuple de
banqueroutiers, de renégats, de déclassés, d’aventuriers suspects,
de colons marécageux, de forbans des deux mondes.
Des fantassins en jaquette rouge, des artilleurs bleus, des
tirailleurs noirs, des officiers en tenue ou en bourgeois tranchent par
leur méticuleuse correction avec le négligé des Levantins, la
malpropreté des juifs, le débraillé des Latins, tandis que la blonde
fraîcheur et la raideur des jeunes misses contraste avec le teint mat
et la gracilité des brunes Gibraltariennes.
Çà et là, cependant, des cheveux blonds émergeant de dessous
une mantille indiquent le mélange des races et prouvent que le
vertueux John Bull n’a pas passé toutes ses soirées au prêche ni
ses nuits dans la chasteté.
 Malgré huit mille hommes de garnison et une population flottante
de matelots de toutes races, gens de grands appétits et de morale
peu farouche, les commis voyageurs chercheraient vainement dans
la ville, des demoiselles « qui vont en journée la nuit ». La Mission
protestante et la Société évangélique pour la surveillance des
mœurs, qui ont pignon sur la rue principale, boutique de vertu et
entrepôt de crétinisation, ne pouvaient souffrir le trafic de Cythère
dans un siège épiscopal d’évêque anglican. Libre aux catholiques,
aux mécréants, aux infidèles d’être impurs ; un protestant ne l’est
jamais, surtout un protestant anglais. Si les privations du célibat
jointes aux aphrodisiaques climatériques harcèlent Tom Atkins [16] , il
doit sortir de Gibraltar et aller dans les villes espagnoles voisines
chercher pâture à ses « impropres » appétits, à San Roque, San
Felipe, Mayorqa, Algéciras, lieux de perdition que les évangélistes
comparent dans leurs prêches aux sept villes maudites ensevelies
dans la mer Morte ; à moins qu’il ne prenne pour autel de ses
sacrifices au dieu Éros la femme ou la fille de son camarade, plus à
sa portée et à sa convenance.
[16] Surnom du soldat anglais.

Que la pureté de tous ces prêcheurs et chenapans bibliques est

odieuse et insupportable ; et comme ces gens font comprendre et
excuser certaines arquebusades célèbres de jadis !
Les drames sanglants de l’histoire nous semblent à première vue
cruels et abominables ; mais, quand on regarde autour de soi, on
arrive à les expliquer comme fatalités nécessaires.
Qui sait si sans ces moyens extrêmes, sans quelques poignées
de très braves mais très insupportables saints passés hâtivement et
brutalement de vie à trépas, les austères luthériens et les rigides
calvinistes n’auraient pas transformé la belle et joyeuse France en
un triste et laid champ de prêche où à l’heure actuelle nous
rivaliserions de vertus publiques et privées avec les pieux hypocrites
d’outre-Manche et les sots moralistes d’outre-Rhin !
 Je ne me trouvais pas en pays nouveau, comptant dans la
garnison une dizaine d’officiers de génie et d’artillerie, vieilles
connaissances de Woolwich, y compris sir John Adye, le gouverneur
de Gibraltar, qui commandait il y a quelques années l’Académie
militaire.
Ma valise repêchée sans trop de dégâts me permit de lui rendre
visite ; mais cette formalité contraire à mes usages fut pour moi un
plaisir bien plus qu’un devoir, plaisir que semble éprouver aussi le
vaillant général qui aime les Français, ayant partagé en Crimée leurs
fatigues et leur héroïsme et qui porte fièrement sur son grand
uniforme la croix de commandeur de la Légion d’honneur.
La très gracieuse lady Adye et lui me font visiter leur palais, car
c’est un palais que cette résidence, ancien prieuré, embelli, orné,
fourni, meublé de tout le confort anglais joint au luxe oriental et où,
entre des galeries mauresques, s’épanouit, sur ce rocher aride et au
milieu de ces bastions, de ces forts et de ces engins de guerre, en
touffes verdoyantes et en fleurs paradisiaques, un vrai coin des
délicieux jardins de Grenade.
Dans la salle de réception sont rangés par ordre chronologique
les portraits des gouverneurs de Gibraltar, gentlemen de grand air et
soldats de haute mine, qui tous, comme les Gomes de Silva, ont
leurs faits d’armes et leur légende.
On sent à chaque pas les constantes préoccupations d’un
gouvernement qui whig ou tory, conservateur ou libéral, a le souci de
ses serviteurs, tient à ce qu’ils représentent dignement le pays,
entourant la fin de leur carrière de respect et de bien-être.
Devenus maîtres de Gibraltar par surprise, les Anglais montrent
bien qu’ils ne sont pas disposés à se laisser reprendre la place. De
1779 à 1782, Espagnols et Français le tentèrent vainement, et si
John Bull perd jamais cette clef de la Méditerranée, ce ne sera pas
manque de précautions.
On a vu que tout étranger ne peut y pénétrer que muni d’un
permis.
 Indépendamment de cela, au coucher du soleil un coup de canon
prévient les gens de la banlieue qu’ils aient à déguerpir de la ville, et
à ceux de la ville qui ont eu affaire au dehors qu’ils doivent regagner
au plus vite le logis. Rien de plus comique que le chassé-croisé qui
commence et surtout la vue des retardataires. Piétons, cavaliers,
amazones, muletiers, âniers, carrioles et fiacres se hâtent d’entrer
ou de sortir. La porte divisée en deux empêche d’ailleurs tout heurt
et tout encombrement.
Le poste est sous les armes, le clairon, l’œil au guet sur l’aiguille
de l’horloge et l’embouchure à hauteur des lèvres, attend la seconde
précise.
Aussitôt la sonnerie éclate, et l’adjudant de place, avec une
régularité de chronomètre, pousse les portes et donne un tour de
clef.
Malheur aux traînards ! Toute supplication est vaine ; tout appel à
la pitié superflu. Le mari jaloux et la femme éplorée sont séparés
pour la nuit. Le règlement n’a pas d’oreille, et l’officier, impassible,
porte gravement les clefs au gouverneur, et, à moins d’un ordre
spécial de celui-ci — ordre écrit, signé et timbré — la porte ne
s’ouvre plus qu’au coup de canon du réveil.
Il y a là matière pour un joli vaudeville.
Eh bien, malgré ces exigences d’une ville de guerre, ou, si vous
le préférez, cette « brutale tyrannie du sabre », pas un Gibraltarien
ne voudrait l’échanger contre les douceurs civiles de l’administration
espagnole. Quand je dis Gibraltarien, je parle, bien entendu, de
l’indigène du Lizard of the rock, comme l’appellent, par dérision, les
habitants des villes voisines, sujet anglais de père en fils ou ayant
obtenu la naturalisation après quarante ans de séjour, et non du
cosmopolite véreux, du forban de l’industrie ou du commerce, qui y
est venu chercher un refuge provisoire.
Ce sentiment est un peu celui des Canadiens, qui nous disent
quand nous les visitons : « Nous aimons les français, nous sommes
Français d’origine et de cœur, mais ne voudrions à aucun prix l’être
de fait. » Aveu peu flatteur ; mais il faut bien reconnaître, entre nous,
qu’il est expliqué par les procédés puérils et vexatoires de notre
administration tracassière, procédés qui peuvent ne pas trop nous
choquer, habitués que nous sommes, dès l’enfance, à être
emmaillotés dans une quantité de lisières, mais qui ne manquent
pas de heurter et révolter l’étranger.
Ce système tout latin « d’embêter les gens » se fait sentir aux
portes de Gibraltar. Dès que vous avez franchi le territoire neutre,
vous êtes littéralement assailli par une escouade de carabiniers
espagnols, embusqués à l’entrée de la barrière de San Felipe, qui
vous entraînent dans une caverne douanière où non seulement
votre valise, mais vos poches sont fouillées de belle façon. Tout se
paye, jusqu’à un cigare, jusqu’à une once de tabac trouvée sur vous.
Il faut dire aussi, pour atténuer l’odieux de ces vexations
internationales, que l’occupation de Gibraltar par les Anglais coûte
annuellement, à l’Espagne, cent cinquante millions, soit par la
contrebande [17] , qui se fait sur une échelle d’autant plus vaste que
les fonctionnaires espagnols, dit-on, y prêtent une main
complaisante, soit en faisant dévier le commerce.
[17] Les gens de Ronda, les Rondanos, ont la
spécialité d’introduire en Andalousie, en dépit de tous les
postes de douane, les ballots de cotonnades et de tabacs
entassés dans les magasins de Gibraltar.

Un autre trait caractéristique, qui ne peut manquer de frapper les

Espagnols eux-mêmes, et j’avoue que si j’étais hidalgo je me
sentirais humilié, c’est l’extrême contraste entre les soldats des deux
nations, séparés par le simple terrain neutre d’un mille environ,
lande sablonneuse qui couvre la partie la plus étroite de l’isthme.
D’un côté, l’Anglais, superbe reître bien habillé, bien nourri, d’une
propreté méticuleuse, aussi correct en faction, dans son poste isolé,
sous sa planche mobile qui l’abrite du soleil, et témoigne en même
temps du souci que l’on prend de sa santé, que lorsqu’il défile la
parade devant le palais de Buckingham ; de l’autre, l’Espagnol, mal
vêtu, mal nourri, débraillé, de méchante mine, allongé dans la
poussière.
 Je suis loin de vouloir dire que l’habillement, la correction et le
bifteck fassent le soldat, et que les petits fantassins navarrais ou
andalous soient inférieurs en rien, sur le champ de bataille, aux
superbes grenadiers du Middlesex ou du Kent ; mais, quand une
nation sait obliger ses soldats, détachés dans les stations les plus
lointaines et les climats les plus divers, à observer le respect de la
discipline, le self control, à garder l’orgueil de l’uniforme aussi bien
que dans la mère patrie, à être d’autant plus fiers et corrects qu’on
est en face de l’étranger ; que de l’autre côté, au contraire, sur le sol
natal, les soldats semblent livrés au laisser-aller, abandonnés à
l’incurie de chefs indifférents ou somnolents, on ne peut manquer
d’établir involontairement une comparaison qui n’est pas à
l’avantage de ceux-ci.
Puisque je parle de soldats, je ne veux pas terminer sans ajouter
quelques mots sur l’armée espagnole encore toute-puissante dans
le pays.
Il n’y a que deux choses, dit V. Almirall dans son excellent livre
déjà cité, l’Espagne telle qu’elle est, pour lesquelles l’Espagne
marche à la tête des nations européennes, et ces deux choses sont :
sa dette publique et le nombre de ses officiers généraux.
Pour une armée qui ne dépasse pas soixante-dix mille hommes
présents sous les drapeaux, elle compte sept capitaines généraux
ou maréchaux, soixante-seize généraux de division, trois cent
quatre-vingt-quinze généraux de brigade, plus six généraux de l’état-
major du roi, en tout quatre cent quatre-vingt-quatre officiers
généraux, c’est-à-dire plus que la France et l’Angleterre, deux fois
plus que l’Italie, presque le double de l’Allemagne.
Et ces chiffres, comme ceux de la dette publique, dont l’intérêt
est de près de trois cents millions, augmentent tous les ans.
Je ne sais rien des officiers espagnols si ce n’est qu’ils sont
d’une courtoisie exquise et plus aimables compagnons que les
Anglais ; mais, s’il faut s’en rapporter à un récent manifeste du duc
de Bourbon, daté de Tarbes (28 septembre 1886), il se serait établi
dans l’armée, comme à Madrid au temps de Figaro, un système
d’espionnage et de dénonciation plus digne de disciples de la
jésuitière de Loyola que des cadets de l’École de Tolède ; « le
colonel est espionné par le commandant, celui-ci par le capitaine, le
capitaine par le lieutenant, l’officier par le sergent. »
J’ajoute que je n’en crois rien pour l’honneur de toutes les
armées.
Avec Gibraltar à l’ouest, l’Égypte à l’est, Malte et Chypre au
centre, la Méditerranée est devenue en quelque sorte un lac anglais
et la Grande-Bretagne semble réaliser à son profit le rêve que faisait
Napoléon pour la France.
Mais le rocher de Gibraltar mérite-t-il bien la réputation que les
Anglais ont contribué à lui faire ?
S’il faut s’en rapporter aux organes militaires, plus compétents en
cette matière que les épiciers du Times, Gibraltar avec les nouveaux
engins de destruction ne serait plus qu’une forteresse fantoche. Sa
force ne repose que sur la routine et les préjugés, les préjugés d’une
nation avant tout marchande, qui a trop longtemps négligé les
choses de la guerre pour être à hauteur du mouvement qui entraîne
l’Europe.
Nous sommes loin en 1888 des batteries flottantes de M. d’Arçon
que les forts de Gibraltar coulèrent en 1783 si aisément, ce qui fit
dire au comte d’Artois accouru de Versailles pour assister au
bombardement de la place que de toutes les batteries françaises,
celle qui se signala le plus, avait été sa batterie de cuisine.
Disons le mot, ou plutôt répétons ce que disent les officiers
anglais eux-mêmes. L’inexpugnabilité de Gibraltar n’est plus à
discuter quand en une demi-heure un cuirassé de cent dix tonnes
peut mettre tous ses forts en pièces !
Quant à commander le détroit et à empêcher les navires de
passer, il suffit de jeter un coup d’œil sur la carte pour en reconnaître
l’impossibilité matérielle. Tant que Ceuta ne sera pas anglais,
Gibraltar peut être utile en temps de guerre comme place d’armes,
comme station de charbon, comme port de refuge, non contre la
grosse mer, car la baie n’est pas sûre, mais contre les croiseurs
ennemis. C’est du moins l’opinion générale. Pour les deux premiers
cas, rien de plus juste ; quant au troisième, s’imaginer que des
vaisseaux trouveraient un refuge sous les canons des forts est une
erreur, par la raison bien simple qu’il n’y a pas à Gibraltar un seul
canon qui pourrait protéger un navire contre un cuirassé, et qu’un
cuirassé de cent dix tonnes mettrait, je le répète, la place en pièces
en trente minutes.
Les ingénieurs militaires reconnaissent eux-mêmes qu’il n’y a
pas moins de quatre points d’où un cuirassé bombarderait aisément
la ville sans qu’un seul canon puisse l’atteindre. Les seules grosses
pièces actuelles sont deux canons Armstrong de cent tonnes
commandés par le gouvernement italien et achetés 50 000 livres
sterling par les Anglais pendant les menaces de guerre de la Russie.
Pièces dites Muzzle-loaders, d’un calibre et d’un modèle hors
d’usage et montées de telle sorte qu’elles ne peuvent balayer la mer.
Mais assez sur Gibraltar et revenons, pour conclure, à l’Espagne.
On dit qu’elle se relève, qu’en nombre de villes le commerce
renaît, que l’industrie s’étend, que Madrid est gai, Barcelone, Séville
et Malaga prospères ! Mais il faut voir l’intérieur, s’arrêter dans les
bourgades ruinées et misérables, où l’ignorance et la superstition
règnent en despotes. Aucun élément de culture moderne, aucune
aspiration vers un mieux matériel, nul sentiment du plus vulgaire
confort. C’est toujours le pays dont parlait Saint-Simon : « La science
y est un crime ; l’ignorance et la stupidité, la première vertu. »
Dans un roman de Fernan Caballero, la Famille d’Alvareda, il est
une vieille qui peut passer pour le type de toutes les paysannes,
jeunes et vieilles, rencontrées dans ma traversée d’Irun à Malaga.
Un de ses petits-fils, revenu de l’armée, raconte avoir entendu dire
par des camarades qu’il existe des pays où l’on ne joue pas du
couteau, où il n’y a ni combats de taureaux, ni frères, ni moines, où
le ciel est gris, le soleil sans brûlants rayons, les églises sans
chapelles, la vierge sans images, où il n’y a ni rosaire ni scapulaire,
et où tous les petits enfants savent lire et écrire ; la Vieille s’exclame
toute frissonnante de joie après la stupéfaction première : « Oh ! mon
soleil, mon scapulaire, mon église, ma Vierge santissima, ma terre,
ma foi et mon Dieu ! Bienheureuse mille fois d’être née ici et d’y
mourir ! Grâce au ciel, tu n’es pas allé à ce pays, fils, pays maudit
d’hérétiques. »
Aussi pas un rayon d’intelligence n’allume leur regard.
L’hébétude seule s’y lit, l’hébétude résignée de la bête passive,
livrée à ses seuls besoins, sa routine et ses instincts. Boire, manger,
dormir, entretenir une lampe devant une image et s’agenouiller deux
fois par jour au pied d’une idole de plâtre ou de bois !
L’Espagne pourra se relever, mais quand elle aura répandu
l’instruction au fond de ses bourgades, non pour qu’elles rejettent
sur le pavé de Madrid des légions affamées de surnuméraires et
d’institutrices, mais pour arracher la population à son lamentable état
d’indifférence et d’abrutissement fataliste.
Elle se relèvera quand elle sera sûre du lendemain, à l’abri des
pronunciamientos ; quand son budget de la guerre n’absorbera pas
la plus grande partie de ses ressources, que la conscription ne
prendra plus tous ses hommes valides, et que son trésor ne sera
plus en état de permanente banqueroute [18] .
[18] La dette flottante se montait, au moment où
j’écrivais ces lignes (nov. 1887), à 112 millions 400 000
pesetas.

Elle se relèvera surtout quand elle aura secoué l’exploitation

anglo-saxonne qui la dévore, lutté contre la concurrence allemande
qui inonde de ses pacotilles tous ses marchés, écrasant les
industries locales, les tarissant à leur source, fournissant les
mantilles à Madrid, les éventails à Séville, la coutellerie à Tolède, la
soierie à Murcie, la faïencerie à Valence, les vins à l’Andalousie et
les alcools partout !

FIN
 TABLE DES MATIÈRES

Pages.
I. Entrée en Espagne 1
II. Les Passages 12
III. De Saint-Sébastien à Deva 17
IV. Le capitaine Bonelli 21
V. Loyola 26
VI. A travers les Andes 40
VII. Le palacio d’Urvaza 46
VIII. Messe au palacio 54
IX. Estella 60
X. Logroño 67
XI. Le col de Piqueras 73
XII. Histoire de brigands 79
XIII. La vieille Castille 88
XIV. Les ruines de Numance et Soria 93
XV. Madrid 101
XVI. Flamencos et peteneras 107
XVII. A los Toros ! 118
XVIII. Les toreros 134
XIX. L’Escorial 140
XX. Tolède 146
XXI. La petite dévote de Compostelle 152
XXII. La Vierge en chemise et le Christ en jupon 158
XXIII. Les bonnes lames de Tolède 164
XXIV. Visite aux fous 170
XXV. Le coin des folles 175
XXVI. A travers la Manche 180
XXVII. Mançanarès 185
XXVIII. El Muradiel 191
XXIX. La Carolina 196
XXX. De Baylen à Cordoue 201
XXXI. Grenade 211
XXXII. Les gitanos 217
XXXIII. Les bandoleros 223
XXXIV. Une exécution 228
XXXV. Route de Motril 233
XXXVI. La posada du Paradis 238
XXXVII. Motril et Malaga 245
XXXVIII. L’auberge du Grand Saint Iago 253
XXXIX. A travers l’Andalousie 259
XL. Séville 263
XLI. Les deux Maria de don Pedro 270
XLII. Les cigarières 277
XLIII. Sur le Guadalquivir 282
XLIV. Cadix 289
XLV. De Cadix à Algéciras 299
XLVI. Gibraltar 304

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