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 role 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 1/4 to 3/4 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 reenforcing 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.
_Calories_
1000 calories per day--
Milk, 1000 c.c. (1 qt.) 700
Cream, 50 c.c. (1-2/3 oz.) 100
Lactose, 50 gm. (1-2/3 oz.) 200
This furnishes eight feedings, each containing
Milk, 120 c.c. (4 oz.) 80
Cream, 8 gm. (2 dr.) 15
Lactose, 6 gm. (1-1/2 dr.) 24
2000 calories per day--
Milk, 1500 c.c. (1-1/2 qt.) 1000
Cream, 240 c.c. (8 oz.) 500
Lactose, 125 gm. (4 oz.) 500
This furnishes seven feedings, each containing
Milk, 210 c.c. (7 oz.) 140
Cream, 30 c.c. (1 oz.) 60
Lactose, 18 gm. (4-1/2 dr.) 72
3000 calories per day--
Milk, 1500 c.c. (1-1/2 qt.) 1000
Cream, 480 c.c. (1 pt.) 2000
Lactose, 250 gm. (8 oz.) 1000
This furnishes eight feedings, each containing
Milk, 180 c.c. (6 oz.) 120
Cream, 60 c.c. (2 oz.) 120
Lactose, 30 gm. (1 oz.) 120
~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. (1/2 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 1-1/4 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), reenforced 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
=========+============================+=================+===============
_Time_ | _Material_ | _Amount_ | _Calories_
---------+----------------------------+-----------------+---------------
6 A.M. |Hot milk | 4 oz. | 78
|Cream | 2 oz. | 76
|Lactose | 1/2 oz. (15 gm.)| 60
| | |
8 A.M. | {Milk | 3 oz. | 59
| {Water | 3 oz. |
|Cocoa {Cocoa | 2 tsp. | 35
| {Cream | 1 oz. | 38
| {Sugar | 2 tsp. | 40
| {Lactose | 1/2 oz. (1 tbs.)| 60
|Egg | 1 | 60
|Toast | 1 slice |
| |(well moistened) | 73
|Butter | 1/2 oz. | 73
| | |
10 A.M. |Buttermilk | 6 oz. | 56
| | |
12 M. |Cream of pea soup | 6 oz. | 300
|Mashed potato |20 gm. | 28
|Toast | 1 slice | 73
|Butter |20 gm. | 84
|Coffee and milk | 3 oz. each | 59
|Cream | 2 oz. | 76
|Sugar | 2 tsp. | 40
|Lactose |20 gm. | 80
| | |
| {Orange juice | 3 oz. | 38
3 P.M. |Orange juice {Egg | 1 | 60
| and egg {Lactose |30 gm. | 120
| | |
5 P.M. |Farina | 3 oz. | 102
|Milk | 2 oz. | 59
|Cream | 2 oz. | 76
|Lactose |20 gm. | 80
|Egg | 1 | 60
|Apple sauce | 1 oz. | 30
|Cream | 1 oz. | 38
|Cocoa | 6 oz. | 108
| or | |
|Tea and | 3 oz. | 0
|Milk | 3 oz. | 78
|Sugar | 2 tsp. | 40
|Toast | 1 slice | 73
| | |
7 P.M. |Gruel | 4 oz. | 102
|Cream | 2 oz. | 76
|Lactose |15 gm (1/2 oz.) | 60
| | |
9 P.M. |Broth | 6 oz. | 18
|Egg white | 1 | 13
| | |
12 M. |Milk | 4 oz. | 78
|Cream | 2 oz. | 76
|Lactose |20 gm. | 80
| | |
3 A.M. |Milk or | 4 oz. | 78
|Malted milk | 1 tbs. | 58
|Cream | 2 oz. | 76
|Lactose |20 gm. | 80
| | | ____
| | Total calories 3145
=========+============================+=================+===========
~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 reenforced or not as
desired. Lactose is the substance commonly used as a reenforcing
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.
~Reenforcing 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, reenforcing 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
(a) Give a sample diet order, using liquids only. Raise the fuel value
of the diet from 2000 to 3000 calories.
(b) Formulate a diet order, using the high calorie diet, fuel value
3500 calories.
FOOTNOTES:
[96] Warren Coleman, University and Bellevue Hospital Medical College,
Visiting Physician, Bellevue Hospital, New York City.
[97] "Diet in Typhoid Fever," by Warren Coleman, "Journal of American
Medical Association," Oct. 9, 1909, Vol. LIII.
[98] "Diet in Typhoid Fever," by Warren Coleman, reprint from "Journal
of American Medical Association," June 9, 1909.
[99] Determined by calorimeter observation from the Russell Sage
Institute of Pathology in affiliation with the Medical Division of
Bellevue Hospital, under Warren Coleman and Eugene DuBois.
[100] "American Journal of Medical Sciences," January, 1912, by Warren
Coleman.
[101] F. P. Kinnicut, "Diets Used in the Presbyterian Hospital," New
York City.
[102] "Journal of American Medical Association," Aug. 4, 1917.
[103] See urinalysis, p. 323.