FOOTNOTE:
[95] In scarlet fever and other conditions in which the kidneys may be involved the above diet is not given unless advised by physician in charge.
CHAPTER XIV
TYPHOID FEVER
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
| 8 A.M. | Milk and coffee, each 120 c.c. (4 oz.). |
| 10 A.M. | Milk, hot or cold, 240 c.c. (8 oz.). |
| 12 M. | Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.). |
| 2 P.M. | Junket with cane and milk sugar. |
| 4 P.M. | Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.). |
| 6 P.M. | Junket with cane and milk sugar. |
| 8 P.M. | Hot milk, 240 c.c. (8 oz.). |
| 10 P.M. | Whey, 180 c.c. with 1 whole egg and sherry. |
| 12 M. | Oatmeal gruel, 120 c.c. (4 oz.) with milk. |
| 2 A.M. | Junket with 60 c.c. (2 oz.) can and milk sugar. |
| 4 A.M. | Milk, 240 c.c. (8 oz.). |
| 6 A.M. | Milk, 240 c.c. (8 oz.). |
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.