It is universally admitted that in no acute infectious disease must more care be exercised with regard to the diet than in enteric fever. The conditions presented by this fever are such as to force upon the practitioner's attention various problems in connexion with the feeding of the patient. When we consider how extremely protracted the illness may be, and how enormous is the amount of tissue waste involved in the process, our tendency is to be liberal in our dietary with a view to maintain the strength of the patient and to shorten his convalescence. On the other hand, when we remember the state of the small intestine, often deeply ulcerated, always more or less impaired in its digestive power, we are rather inclined to cut down supplies of nourishment to the lowest possible amount, in the fear lest by giving too much we may but aggravate the condition. The result is that the dietaries which have been recommended for enteric fever vary from what might be fairly described as a full diet to what might, without injustice, be termed no diet at all. Between these extremes there is an extraordinary choice of dietetic systems, all of which are claimed as having given admirable results.
The results obtained by systems, very different in theory, but apparently equally successful in practice, almost lead us to the heretical conclusion that diet, after all, is not a matter of such supreme importance in enteric fever. Patients often do admirably with large quantities of solid food. Others do equally well on a diet from which all solids are excluded, or which may be even limited to small quantities of water alone for days at a time. If any deduction is to be made from this it is, I think, that the condition of the food when it reaches the small intestine is a matter of much more importance than its condition when it is offered to the patient. The residuum left by milk may be, and often is, far more irritating to the intestine than the residuum of a mutton chop. Another point worth considering in this connexion is that in many cases of enteric fever the bowel is very slightly affected. In many cases, fatal from toxaemia, the intestinal lesions are most insignificant, and occasionally are wanting altogether. Probably, a considerable proportion of the patients who recover have but little ulceration, and of them it would be certainly fair to conclude that they would get through the fever whether their diet was solid or fluid.
The most reasonable course to take in prescribing a diet for an enteric patient is, I think, to treat him as a patient and not as a case, and to modify the dietary according to his personal idiosyncrasies and the character of his illness. On the other hand, it is highly desirable to have some definite line of treatment, and the diet must necessarily be such as not to interfere in any way with the theory on which that treatment is based. It is my intention in this article first to describe a dietary which may be used with advantage whether the patient is treated expectantly, with antiseptics, or with cold baths; secondly, to discuss the modifications which may be called for in the presence of certain complications; and lastly, to give some account of special dietaries which have been suggested by various writers, and which seem to me to be worthy of notice. The practitioner, however, whose experience of treating this fever is limited, will do well to rely, at first at any rate, on a dietary more or less on the lines indicated below.
The value of milk as a food in any fever is, of course, beyond all question, and it is still recognized by most authorities as the most suitable form of diet for cases of enteric fever. Still, if the greatest care is not taken, there are few foods which are capable of doing more harm. The famous epitaph of Graves has, perhaps, been responsible for a tendency to overfeed fever patients. Overfeeding, if the staple article of diet is milk, may be very dangerous, as if more is ingested than the patient's alimentary system can adequately deal with, large masses of undigested curd are left to irritate the ileum and the lower bowel. The result is meteorism or diarrhoea, which are always dangerous and too often fatal. On the other hand, it is not enough to merely limit the amount of milk which is to be given in the twenty-four hours. Even moderate and reasonable quantities, given improperly, may cause much mischief. The most common error, one far too frequently met with, is to allow the milk to stand at the patient's bedside. As a result, it is used to quench his thirst, and small amounts are taken at very short intervals. Undigested milk is mixed with partially digested and completely digested milk in the stomach, and the whole mass may be passed on into the duodenum very imperfectly treated by the gastric juices. The consequence is that the stomach gets no rest, and the intestine is asked to deal with masses of curd. Under such circumstances it is quite impossible to expect good results.