Pathological Physiology

Careful nursing and diet regulation are the life-saving agents in typhoid fever. In few diseases does a closer relation exist between right feeding and symptoms.

In average cases the fever lasts a month, no matter what the treatment, whether by cold bathing or otherwise, while in some it continues for five or even six weeks. There is then a convalescent period of at least two weeks, and often as many months, during all which time constant care in feeding must be exercised. At any time during the prevalence of the fever the slightest departure from the strict rules for diet laid down by the physician may determine a fatal issue, but it is during the period of ulceration that the greatest danger is met.

The ulcers involve the Peyer's patches and solitary follicles in the lower end of the ileum, but they may extend into the jejunum, and even into the large intestine. They are deep and clean-cut, often including the whole thickness of the muscular layers, and sometimes perforating through the serous layer. An overloaded intestine or a distended bowel may precipitate perforation at any moment. It is therefore important to select a diet which will leave but small residue.

More or less intestinal as well as gastric catarrh is often present, interfering with both digestion and absorption.

The prolonged fever is itself a menace to life by the secondary changes which it induces in the alimentary system. The digestive secretions are altered in quality and lessened in quantity. Enfeebled circulation retards or inhibits absorption, and the functional activity of the liver is in abeyance.

Poisonous products suspended in the blood, as well as its elevated temperature, interfere with the normal rate of metabolism through the body, and finally the excretory organs are overworked. The typhoid bacillus has curious behavior in relation to certain food materials, e. g., if cultivated in milk it prevents coagulation; whey cultures become distinctly acid, and potato cultures show peculiar modes of growth.

Dietetic Treatment

There are two chief factors which should influence the selection of a proper diet for typhoid fever. These are: I. The supposed danger of mechanically irritating the ulcerating surfaces in the intestine and the danger of overloading an intestine and stomach whose digestive functions are impaired by fever. 2. The relations of the chemical ingredients of the food to the increased tissue change that causes or accompanies the excessive production of heat. If the proper fuel can be furnished as food, the tissues are spared too great self-consumption in producing heat.

Milk Diet

In regard to the first factor the danger of mechanical irritation of the intestinal wall is somewhat exaggerated. In prescribing a milk diet for typhoid fever in order to lessen this danger many overlook the fact that undiluted milk, on entering the stomach, becomes almost solid, and large firm milk curds are likely to prove quite as irritating to the ulcerating surfaces, or even more so, than are starchy foods.

When patients are fond of milk and digest and absorb it thoroughly, there is no better diet for typhoid fever, and it answers every requirement of a fever food. It contains all the essential elements of nutrition, is easily digested, furnishes fluid to the tissues, is a good diuretic, and, if properly administered, in many cases it is soothing to the stomach when a mild degree of gastric catarrh exists.

Those who dislike milk at first may later grow accustomed to it and take it contentedly for a month or even six weeks.

Due emphasis should be given to the fact that an exclusive milk diet need not and should not be prescribed in routine for all cases. Within the past few years a number of writers (notably Shattuck of Boston and A. G. Barrs of London) have advocated a departure from the strict milk diet which had come to be the rule for typhoid fever, and it is found beneficial to enlarge the dietary of some patients considerably by such articles as strained vegetable soups, boiled rice, macaroni, soft-cooked eggs, soft cream toast, cream and water, buttermilk, softened soda crackers, blancmange, wine jelly, and ice cream. It is much easier to put all hospital cases of typhoid fever on a routine milk diet, but it is often better to devote a little study to securing suitable variation in the food.

In typhoid fever every effort should be made to maintain good stomach digestion. If all food is thoroughly disintegrated before it enters the intestine there need be little fear of a mechanical irritation of the ulcerating surfaces. Far more danger may occur through malnutrition of the intestinal wall, which prevents absorption of nutriment. An accumulation of undigested food in the intestine is therefore highly undesirable, and the stools should be periodically examined to see that undigested milk curds do not appear in them.

Milk for some persons in health is really a poison. They completely fail to digest it. It causes constipation with clay-coloured or white stools, and fills the bowels with products of malfermentation, ptomaines, and gases. They digest it even less when they acquire a prolonged fever. Others, with whom the milk agrees, become very tired of it after taking it exclusively for several weeks at a time.

I have several times seen cases of typhoid fever with symptoms which resembled scurvy, with swollen and bleeding gums and great emaciation, occurring in patients who had been fed too long upon an exclusive milk diet which they failed to assimilate.