Definition.—Typhoid fever is an acute infectious disease excited by specific bacteria (Eberth). The intestines become the seat of ulcerations (Peyer’s patches), which at times perforate. The chief symptoms of the disease are fever, headache, abdominal distention and tenderness, more or less diarrhea and a rose-colored abdominal rash. The source of infection is found in the intestinal contents of a typhoid fever patient, which in some way come in contact with and infect drinking water, milk, etc.

Energy Expenditure in Febrile Conditions.—In febrile conditions the energy expenditures increase as much as twenty-five per cent. In some cases, and when bacterial activity is added to this, as is the case in typhoid fever, the tissue waste becomes correspondingly greater; hence the nutrition assumes the chief rÔle in such cases, for in no other way can the tissue waste and energy expenditure be met and overcome.

Energy Expenditures in Typhoid.—In typhoid fever the problem of meeting these expenditures, and at the same time protecting the heart and kidneys from the abnormal strain placed upon them in handling the toxic substances produced as the result of bacterial action in the intestines, becomes very real. It requires eternal vigilance and patience not only from the physician but especially from the nurse, with whom so much responsibility rests. The dietetic treatment necessarily is the principal point to which all efforts must be directed. By this is understood not only the type and amount of food given the patient, but the behavior of this food in the body as manifested by the symptoms, namely, the appearance of the patient, the condition of the mouth, the abdominal distention, tenderness, diarrhea, nausea, and vomiting, the hemorrhage which at times occurs in spite of all care, and perforation which sometimes results in death, and acidosis or acetonuria. All of which makes this disease one requiring the most efficient attention from a nutritional standpoint.

Energy Requirements in Typhoid Fever.—In a previous chapter the energy expenditures of the normal individual were dealt with; it was seen that a man at rest, that is, in bed, not rising for anything, had a normal expenditure of energy requiring from 1900 to 2200 calories per day. Now, if these expenditures were increased twenty-five per cent. by the fever and still more by the bacterial activities, it is clearly seen that the diet must be increased in proportion if the tissue waste is to be prevented and the normal body weight of the patient maintained.

High Calorie Diet.—Dr. Warren Coleman,[96] to whom we owe so much for his pioneer work in feeding in typhoid fever, devised the so-called “High Calorie Diet.” This consists of foods of the most digestible type prepared in the simplest way. The weight of the patient is considered and the diet directed with the following points in view: (1) to cover the energy requirements of the body; (2) to make good the tissue waste which at times amounts to a loss of from 15 to 20 grams of nitrogen a day (or from ¼ to ¾ pound of muscle);[97] (3) to check or prevent the development of serious complications, kidney, heart, etc.

In the Metabolism Ward at Bellevue Hospital, New York,[98] the best results are obtained by the giving of diets furnishing from 60 to 80 calories per kilogram per day, or from 4000 to 5500 calories.

Fluid Diet.—It is clearly seen that it would be practically impossible to obtain a sufficient number of calories by using milk alone or even a mixed fluid diet to supply the above requirements. Since milk alone in such a diet would probably cause such discomfort as to make it unwise to continue it, the ideal diet would seem to be one in which the fats, proteins and carbohydrates are furnished in a semi-solid or solid form, together with a sufficient amount of liquids to prevent too great concentration in the food, to relieve thirst, and to act as a carrier of reËnforcing substances, such as lactose, eggs, casein products, etc.

Absorption Food.—The question as to whether the food is absorbed when given to typhoid fever patients has often been asked. That it is has been proved in the series of calorimeter experiments conducted in the Metabolism Ward, Bellevue Hospital.[99] Here it was demonstrated that under the high calorie diet the patient consumed large amounts of food with relish and that which was not utilized by the organism immediately was stored for future needs.

Diarrhea and Tympanites.—Constant attention and study of various typhoid patients taking a maximum amount of food a day has proved that the diarrhea and tympanites which at times occur in these as well as other cases are due to too much of one or another of the food constituents rather than to the general amount of the diet. Diarrhea may then be traced to an excess of cream, and the tympanites to an excess of lactose, and a reconstruction of the dietary will often obviate the trouble.

Increasing the Diet.—It is always advisable to “go slow” in adding new foods to the diet; milk, cream, eggs and lactose are the principal articles constituting the diet. To this are added fine cereal gruels, well-cooked rice, rice custard, tapioca custard, junket, ice cream, wine or fruit jellies, toast, eggs (soft-cooked, poached, creamed, or raw, in milk), or fruit beverages, cocoa, buttermilk, koumiss, certain proprietary infant foods such as Mellin’s Food, Eskay’s Food, Racahout and malted milk, with a well-baked potato, milk, cream or buttered toast added as the condition and appetite warrant.

Milk Diet.—The following milk diets[100] were devised by Dr. Coleman to be given in certain cases of typhoid fever during the acute stage. These formulas consist of milk, cream and lactose and furnish from 1000 to 3000 calories per day.

Varying the Diet.—It has been found possible, even advisable, to vary the above diets in many cases. The disease extends over such a long period that if a fluid diet is adhered to the patient would grow exceedingly tired and even disgusted if milk alone was given, hence a mixed fluid diet such as is used in the Presbyterian Hospital, New York City is suggested.[101]

PRESBYTERIAN HOSPITAL DIET LIST

15 gm. (½ oz.) of lactose added to each of the four milk feedings.

The following foods and diet lists are used with success in various hospitals:

From 1 to 1¼ quarts of milk and 1 pint of cream and lactose, beginning with 1 tablespoonful in each milk feeding and raising the amount day by day until the patient is taking 2 oz. (4 tablespoonfuls) at each milk feeding, given in eight feedings. This may be given as milk, hot or cold, or it may be made into cocoa, soup, ice cream, junket, or on the cereal.

LIQUID DIET

Milk.
Cream.
Buttermilk.
Whey.
Koumiss.
Zoolak.
Fermillac.
Albumenized fruit juices, egg, and orange juice.
Milk shake.
Broths (chicken, beef, mutton or clam), reËnforced with lactose or egg or given plain.
Proprietary infant foods.
Cream soups, beef juice, liquid peptonoids, panopepton.
Orangeade.
Lemonade.
Eggnog.
Milk punch.
Malted milk.
Malted milk shake.
Albumenized milk.
Strained gruels (except oats).
Cream, egg and vichy.
Chocolate malted milk.
Milk gruels.

SOFT OR SEMI-SOLID DIETS

Eggs—creamed, soft-cooked, poached, custards, baked custards.
Toast—milk or cream toast.
Gelatin—meat, fruit, or wine jellies.
Junkets—plain, egg, or cocoa.
Cereals—fine, strained cereals, except oats.
Rice—boiled or in custard.
Tapioca—custard.
Baked or mashed potato.
Cornstarch or arrowroot pudding.
Ice cream.

Meat is not given until convalescence is established, and then in only the most digestible form, such as rare beefsteak or lamb chop or a small piece of broiled breast of chicken.

Diet List Used in High Calorie Diets for Typhoid Fever

Advantages of Newer Treatment.—A marked difference is noticed in the patients treated by the old starvation diets and those given the high calorie diet. Dr. Coleman states[102] that while the range of temperature is apparently unaffected, the total duration of the disease is shortened in some instances by months through the shortening of convalescence. He further states that certain symptoms which have hitherto been attributed to the specific action of the typhoid bacillus have been discovered to be due to faulty methods of treatment, particularly to an inadequate or improperly balanced diet. The various investigators who have made the study and treatment of this disease a lifework claim that the mortality from this disease has been tremendously reduced by the use of the high calorie diets which maintain the nutrition of the patient throughout the disease, thus eliminating the horrors of the long, tedious convalescence which tried the nerves and patience of the patient, the nurse, and the physician. There is no doubt that so far as the administering of this diet is concerned it requires more effort on the part of the nurse than the old treatment of a glass of milk every two or three hours. It is necessary for the nurse to be able to carry out the orders as expressed in the diet lists, to be able to compute the proteins (nitrogen), fats, and carbohydrates in a food or recipe. But this is readily done by studying the tables given in the first section of this text. She must likewise be able to recognize the symptoms as they arise. In hospitals, the urinalysis is made as a routine procedure. In private cases the physician will either have the analyses made or expect the nurse to be able to make the simple tests.[103]

One of the greatest difficulties attending the administering of the high calorie diet is persuading the patient to take sufficient food for his needs. The fluids are often more difficult to give in quantity than the more solid foods, and it requires much tact on the part of the nurse to prevent a refusal of the necessary fluids. However, if the patient is possessed of even ordinary intelligence, an explanation of the reasons for the large amount of food will as a rule be all that is necessary. Few individuals will willingly prolong an illness attended with the discomforts generally present in typhoid fever.

Hemorrhage occurs in a certain percentage of cases of typhoid regardless of the diet, whether it be a strictly milk diet or the high calorie diet just described. The measures to combat them are essentially the same. It is necessary to guard against excessive tympanites since the pressure therefrom against the ulcerated intestinal walls may cause perforation resulting in hemorrhage. Lactose at times causes an evolution of gas as do fats under certain circumstances. Hence it is necessary to follow symptoms and watch the stools in order to determine which food material is to blame for the tympanites and reduce the allowance of that food in the diet.

Idiosyncrasies against Milk.—Certain individuals manifest an inability to take milk. This may be real or imaginary. When it is a true idiosyncrasy, it may be found necessary to substitute some other food for the milk in the diet, but great care should be taken to determine the real character of the disagreement before eliminating so invaluable a food from the diet. When the disagreement proves merely a distaste for milk, some of the different methods used in disguising it, such as flavoring or coloring, may be practiced. Otherwise, it is well under the circumstances to use some of the pre-digestive methods in order to increase its utilization. It is well to emphasize the value of accurate data on this subject as it is exceedingly difficult to administer a high calorie diet without milk in some form.

Essential Points.—Thus the dietary in typhoid fever is seen to be the most important part of the treatment. A careful study of the tables will enable the nurse to do her part in nourishing the patient. It is necessary that she be able to compute the nitrogen, carbohydrates, and fats in a diet and arrange these constituents in such a way as to give the desired amount of each in the dietary and in a form acceptable to the patient.

SUMMARY

Rate of Metabolism is greatly increased in typhoid fever even over other febrile conditions, not only on account of the elevation and duration of the fever, but also on account of the activities of the specific bacteria in the intestinal tract which differentiate this disease from other febrile conditions.

Energy Expenditures and Requirements of the body in typhoid fever, on account of the character of the disease, are much greater than those of the normal individual and must be met by an increase in the diet if the body is to be saved from destruction.

The Bowels.—Diarrhea develops during any period of the disease due to excess amount of fat or to a disagreement of some of the other food constituents. It is advisable to cut down the allowance of cream temporarily and to watch stools and other symptoms for evidences of dietetic errors.

Hemorrhage must be guarded against by eliminating, as far as possible, all substances liable to cause an excessive gas formation in the intestines.

Absorption of Food is as a rule good. The patient is usually able to handle a large quantity of food provided it is judiciously administered with a due regard to the symptoms manifested at the time.

Simplicity of Diet is absolutely essential. All the materials must be selected carefully according to the physician’s orders and prepared with the greatest care in order to prevent digestive disturbances.

High Calorie Diet is one in which the fuel value of the food ingested meets or exceeds the energy expenditures of the patient. Foods composing the diet are, milk and eggs for the proteins, with carbohydrates and fats in their simplest and most digestible form to balance the diet.

Administering a High Calorie Diet is accomplished successfully provided the nurse exercises care with regard to the symptoms arising from time to time. These must be carefully noted and reported to the physician, for in this way only is it possible to give a sufficient quantity of food to cover the excessive breaking down of the body due to the disease.

Fluid Diet is at times necessary since certain patients cannot tolerate a high calorie diet, but this is a point decided by the physician. A fluid diet consists of fluids alone, milk in particular, with broths and fruit beverages as ordered. The milk is given in definite amounts and at stated intervals.

Milk Diet is one consisting solely of milk or in which the bulk of the nourishment is furnished by milk. It may be reËnforced or not as desired. Lactose is the substance commonly used as a reËnforcing agent. It is impossible to cover the energy expenditures of typhoid fever with a milk diet even if it is perfectly administered, but certain complications make it, at times, the only rational method of feeding.

The Advantages of High Calorie Diet over other diets are distinctly noticeable in typhoid fever patients. Those treated by this method are more comfortable during the course of the disease and are saved a long, tedious convalescence which has made the starvation treatment a thing of horror in the past. The return to health is attended by a much better physical condition when the patients are well nourished than is possible when they are kept on practically a starvation ration. The mortality from the disease has been materially lessened by the administration of the high calorie diet.

Acidosis may develop in typhoid fever patients and must be guarded against. The behavior of the fat in the body should be carefully watched and the amount reduced at the first evidence of acidosis. At the same time an increase in the carbohydrates may assist in overcoming the condition. This adjusting of the diet, however, is entirely in the hands of the physician.

The Kidneys in typhoid fever patients are under a great strain, chiefly on account of the increased rate of metabolism. Great care must be exercised in the dietetic treatment to prevent these organs from being overworked with a consequent development of nephritic conditions.

Care of the Mouth in any febrile condition is important, but especially so in typhoid fever, where the disease itself causes a most unpleasant taste in the mouth. This prevents the taking of nourishment with any degree of comfort, hence the mouth should be cleansed before and after each feeding. Any of the aseptic mouth washes may be used.

Thirst may be relieved by plain or carbonated waters, fruit beverages, and crushed ice. When in certain complications the fluids in the diet are in a measure restricted, ice is used and water is given in spoonful doses. This, however, is the exceptional, rather than the ordinary state of affairs.

Increasing the Diet after a fluid diet must be made with great care in order to prevent a relapse. Following the high calorie diet the increase is simple. The patient passes from the prescribed foods to meat with apparently no effort. The increase should not be made, however, until convalescence is firmly established.

ReËnforcing the Diet.—On account of the great increase in the rate of metabolism and because of the difficulty of furnishing the requisite number of calories in the diet, reËnforcing agents such as lactose, eggs, some forms of casein, or beef preparations are used.

Idiosyncrasies against certain foods are, at times, manifested by patients. Efforts must be made to determine whether they are real or imaginary before eliminating any food which may be of importance to their future welfare.

PROBLEMS