Rules For Feeding In Atypical Cases

If at any time during convalescence after several days of a normal temperature it begins to rise above 100° or 100.5 ° F. it is safest to return at once to fluid diet. If the temperature falls again in a day or two, convalescent diet may be resumed. A sudden rise to 1030 F., or even higher, lasting but a day or two, may be caused only by constipation, and it is not to be considered as a genuine relapse, but until the cause is ascertained the above precaution must be observed.

There is a class of patients in whom the thermometric record is likely to fail as a guide for feeding unless it is correctly interpreted. After a protracted fever lasting four or five weeks the temperature falls to about 100° F. and fluctuates daily up to 100.50 or 101.50 F. without reaching the normal, or it may become subnormal and fluctuate between 97.50 or 980 F. in the morning, and 1010 F. in the afternoon. These patients, in the absence of any sequelae to account for the temperature elevation, have a "starvation fever," and they are usually considerably emaciated. It is necessary to give them solid food cautiously to bring the temperature to normal. Sometimes even then the fever lasts until they are allowed to sit up.

In estimating the proper time for giving solid food, regard must always be paid to the general severity of the disease.

Complications, such as an abscess or furunculosis, may protract the fever, although the intestinal ulcers are completely healed, and such patients should have solid food in spite of a slight elevation of temperature. Patients who have been very ill with repeated haemorrhage or hyperpyrexia should be fed with the greatest caution during convalescence.

Many recent writers among those with largest clinical experience with typhoid fever advocate a liberal diet throughout the disease in ordinary uncomplicated cases, giving semi-solid food before the temperature has become normal. Of recent years I have adopted this practice, with benefit in many selected cases. Relapses are rarely, if ever, induced by judicious increase in diet, and the patient is often better able to withstand a relapse, having been strengthened with more food. As a sample of a liberal dietary, such as that above referred to, Frederick W. Shattuck's may be quoted; he recommends for use throughout the fever such articles as the following named:

Milk, hot or cold, with or without salt, diluted with lime-water, soda-water, apollinaris, vichy, peptonised milk, cream and water, milk with white of egg, slip, buttermilk, kumiss, matzoon, whey, milk with tea, coffee, cocoa. Soups: Beef, veal, chicken, tomato, potato, oyster, mutton, pea, bean, squash; carefully strain and thicken with rice (powdered), arrow-root, flour, milk or cream, egg, barley. Horlick's and Mellin's food, malted milk, panopeptone, bovinine, somatose. Gruels: Strained corn-meal, crackers, flour, barley-water, toast-water, albumen-water, with lemon-juice. Icecream. Eggs, soft-boiled or raw, eggnog. Finely minced lean meat, scraped beef; the soft part of raw oysters; soft crackers with milk or broth. Soft puddings without raisins; soft toast without crust; blancmange, wine jelly, apple-sauce, and macaroni.

The objection that particles of solid food may act as mechanical irritants, erode a partially or recently healed ulcer, and thereby induce relapse, is hardly consistent with the modern view of typhoid fever, as a disease in which the germs are by no means confined to the alimentary canal, but are widely distributed throughout the body.

Many so-called "relapses" are not relapses at all, in the ordinary sense, but are cases of mixed infection or some form of autointoxication. Of course, it would not be maintained that a diet of corned beef and cabbage may not produce great intestinal havoc and perhaps induce fatal haemorrhage, but I do maintain that a carefully increased dietary such as that described is not a cause of relapse. I have seen many dietetic misfits, in which over-zealous friends had smuggled improper food to hospital patients, yet without producing relapse, and on the contrary, many relapses occur while the patient is still taking only a milk diet.

Typhoid fever is essentially a disease of so-called "relapses." About ten per cent of all cases are followed by relapse, no matter what the treatment. It fell to my lot to treat some two hundred cases of typhoid fever among the soldiers who returned from the Spanish War, and I was much impressed by the comparatively slight effect which a perfectly irrational diet had had upon them - relapses were not more common among them than the average, which merely shows that the ulcerated intestine may be more tolerant of food than is generally supposed.

At the end of a fortnight of normal temperature, if the bowels are moving regularly and if there is no diarrhoea, the patient may usually be allowed to select his own menu, although he must be warned to avoid for a long time eating food likely to leave much insoluble residue, such as raw vegetables, raw apples, soft-shell crabs, berries, green corn, old peas, beans, cabbage, tough meats, dried fruits, etc. He must be instructed also not to excite diarrhoea by eating too much fresh fruit. With any attack of indigestion he must return for a few days to a very simple diet. I have seen a second distinct relapse occur on the twentieth day after the first, but such cases are fortunately quite exceptional.