Diet In Typhoid After Two Days Of Normal Temperature

First Day

Chicken broth thickened with thoroughly boiled rice.

Milk toast or cream toast once only during the day. Beef juice.

Second Day

Junket, mutton broth, and bread crumbs. Cocoa.

Milk toast. A piece of tender steak may be chewed but not swallowed. One of the prepared farinaceous foods, such as Horlick's, may be given with a cup of hot milk.

Third Day

A small scraped beef sandwich at noon. A soft cooked egg or baked custard for supper. Boiled rice or potato purge strained. Arrowroot gruel.

Fourth Day

The soft part of three or four oysters. Meat broth thickened with a beaten egg. Cream toast. Rice pudding or blanc-mange and whipped cream, or Bavarian cream.

Fifth Day

Scraped beef sandwich. A tender sweetbread. Bread and milk. A poached egg. Wine jelly or calf's foot jelly.

Macaroni.

Sixth Day

Mush or crackers and milk, scrambled eggs, chicken jelly. Bread and butter. The soft parts of raw oysters.

Seventh Day

A small piece of tenderloin steak or a little breast of broiled chicken. Bread and butter. Boiled rice. Wine jelly.

Sponge cake and whipped cream.

Eighth Day

A slice of tender rare roast beef, a, thoroughly baked mealy potato served with butter or mashed with cream.

Other food as before.

Ninth Day

A little broiled fresh fish for breakfast. Beef steak at dinner. Rice, macaroni, eggs. Sago, rice, or milk pudding.

A baked apple.

Tenth Day

Mush and milk. A squab or breast of partridge or roast chicken. Other foods as before. Ice cream.

1W. Gilman Thompson, M.D.: "Practical Dietetics." New York. D. Appleton & Co.

For the next four or five days the patient may select articles from the menu of the previous day, so that three good meals a day are taken, besides three or four glasses of milk between meals.

It is often desirable to give a little alcoholic stimulant, especially if there is much difference in the frequency of the pulse between lying and sitting or standing, or if the pulse rate is very low, say 56, as it sometimes is. A glass of sherry or a good, sound Burgundy, or a tumbler of ale may be drunk, but with meals only.

Diet In Typhoid After Two Weeks Of Normal Temperature Presbyterian Hospital

Strained vegetable soups, baked apples, baked potatoes, oatmeal.

Typhoid Delicacies Presbyterian Hospital

Rice (well cooked), junket, custard, gruels, milk toast, scraped beef, eggs.

Typhoid Extra Diet Presbyterian Hospital

Broths, beef soups, oysters, white fish, beef, chops, mutton, steak, custard, eggs, chicken, rice, white bread, toast, farinaceous puddings.

Avoid vegetables, fruit, pastry or hot bread.

Liberal Diet In Typhoid Fever

Shattuck 2 When typhoid fever kills it does so either by perforation or exhaustion, the proportion of the former being estimated at 5 to 10 per cent. The main factors in producing the exhaustion which causes the death of at least nine-tenths of the fatal cases are toxemia, continued fever, diarrhoea and vomiting, and intestinal hemorrhage. The heart is ordinarily the best index of the presence and degree of exhaustion, and the most frequent serious pulmonary complication, hypostasis, in its various forms, degrees and consequences, is the direct outgrowth of the cardiac weakness. Moreover, typhoid fever is not short and sharp like pneumonia, but of long course, and usually attended with decided, often with very great wasting of the muscular and fatty tissues.

1 Diet used at the Presbyterian Hospital, New York.

2 Frederick C. Shattuck, M.D.- Bead by title in the Section on Practice of Medicine at the Forty-eighth Annual Meeting of the American Medical Association at Philadelphia, Pa., June 1-4, 1897.

Most of us are agreed that we are not as yet acquainted with any therapeutic measures which will either abort or very materially shorten the course of the disease. We are, I think, unanimous in believing that husbanding the strength from the start through skillful nursing, the judicious use of water externally and internally, and the supervision of a wise attendant on the watch for and prepared to meet such indications as may arise, materially modifies the course of the disease and lessens its mortality. If what I have assumed to be facts be really facts, the question of diet must be a very important one in the management of typhoid fever. It is through the food which is assimilated, not through that which is merely put into the stomach, that we seek to limit the tissue waste while the process is active, and also try to land the patient on the low shore of convalescence with as much of his property as may be; for the recovery of his property is a necessary preliminary to the attainment of the high tableland of full health.

Under the old doctrines as to inflammation, fever was an unfailing indication for depletion; directly by venesection, pukes, sweats and purges; indirectly by starvation. Indiscriminate direct depletion is now a thing of the past, and since the time of Todd the fact has gradually been more and more clearly recognized that the febrile state is often an indication for more, rather than less, nourishment, with selection as to quality, rather than diminution as to quantity. In the shorter essential fevers a few days' starvation cannot do much harm, and may even be of great service with a certain class of patients. But suppurative fever for instance, whether of tubercular or other origin, especially if chronic, we feed to the largest limit; and we do this because we treat the condition and not the disease, individualizing our cases. Since our knowledge of gastric chemistry has been enriched by the adaptation of the soft catheter to another hollow viscus at the opposite extremity of the abdomen, a more complete explanation has been afforded for the fact which we knew by practical experience before, that gastric digestion is often weakened in the febrile state. But the same practical experience teaches us that it is not always so, or very materially so, and when theory and practice conflict, the former must prevail. Have we not fully escaped from the domination of the old doctrine as to the lowering treatment of inflammation, or are there valid reasons why we should be less bold in feeding our typhoid patients than our chronic febrile consumptives? Three such reasons deserve special consideration. In the first place, typhoid is far more frequently a self-limited disease than is phthisis; but the fact of a self-limitation does not seem to me to warrant us in underfeeding, for the less the patient loses the less does he require to regain. In the second place, typhoid has constant intestinal lesions which may bleed or perforate, and which may be accompanied by a general catarrhal state of the intestinal tract. I may perhaps add here that diarrhoea is not nearly as constant a symptom in typhoid fever as the books lead students to believe. In at least 50 per cent. of my hospital cases no diarrhoea was present at any time. We must therefore have reference to the local intestinal lesions as well as to the general state. In a disease of such long course it is impossible to prevent accidents by putting the bowels in splints, even if it were desirable to do so. More or less peristalsis must go on, and waste matter must pass over the ulcerated surfaces; and how deep or extensive the ulcerated surface may be in any particular case no symptom or group of symptoms enables us to measure. Hence, it seems rational, quite apart from the fever, to withhold from the diet any articles the residue of which is liable to irritate either the mucous membrane in general or the ulcerated portion in particular. This would seem a fair explanation for the popularity of milk as a diet for typhoid, containing as it does a large proportion of water, and every principle necessary to nutrition, so combined as to make relatively small demands on the digestion of most persons, and leaving a residue which, though notoriously large, is not mechanically irritating. The objection to milk is that it is repugnant to a few persons, and becomes either repugnant or monotonous to a considerable number sooner or later. It is not necessary here to specify the many expedients which may and often must be resorted to to overcome this objection, and in some cases to render it digestible whether palatable or not. Milk is likely to maintain a very important, perhaps leading place in the diet of typhoid, as well as of other diseases and conditions. For a number of years I adhered as strictly as possible to an exclusively milk diet in typhoid fever until at least a week had elapsed from the date of the first normal evening temperature. I closed my ears to the clamors of adults, and my eyes and heart to the tears of children, as I now believe, unnecessarily. Thirdly, it was only comparatively recently the general opinion of the profession that relapse is or may be due to errors in diet. I well remember the time when a fresh access of fever led my teachers and me to carefully inquire into the kindness of officious friends. It was often proved that forbidden fruit actually or metaphorically had been brought in by a visitor, and this was an entirely satisfactory explanation. When proof could not be had, the fact of relapse was strong presumptive evidence of sin. We know better now, and while we recognize that errors in diet may produce fever, as may fatigue or excitement in convalescence from any severe disease, we do not believe that they can start up a fresh invasion of bacilli from within. One of the things which set me thinking on this question of the diet in typhoid was the favorable course run by several acute febrile cases for whom I ordered a full diet because they were weak; believing at the time of so doing that typhoid could be excluded, but being forced to the conclusion later that only typhoid fever could explain the whole course of the disease. These patients did perfectly well, were happier and convalesced more rapidly than my recognized typhoid cases fed exclusively on milk. For five years now, I have been enlarging the diet of my typhoid cases, and have seen no reason to regret this course, but, on the contrary, found cause for satisfaction.

During the twelve years, 1886 to 1897 (both inclusive), 380 cases of typhoid fever have come under my personal care in the Massachusetts General Hospital. From 1886 to 1893, 233 cases were treated under a milk diet, with a mortality of 10 per cent. From 1892 to 1897, 147 cases have been treated under a much more extended diet with a mortality of 8.1 per cent. I know well the liability to reach false conclusions in reasoning from too small figures in a disease like typhoid fever. And it is also true that water has been used more efficiently of late than in former years. But I can see nothing in my figures to contravene my observation that an enlarged diet has not been injurious. I would not be understood as advocating an indiscriminate diet. My plea is simply for treating the patient rather than the disease; for feeding him with reference to his digestive power rather than solely or mainly with reference to his fever; for the view that the danger of accidents from the local intestinal ulceration is not increased by allowing him to partake of articles which leave no irritating residue, and which cautious trial shows are digested without disturbance or discomfort. At one end of the scale are the cases with such irritability or weakness of the stomach as to lead to the unfortunate term gastric fever, or those with pronounced diarrhoea and undigested food in the stools; at the other end are those more numerous cases with clean tongue and a desire for food. Between the two is every gradation. The life of the former may depend on the skill and ingenuity of the doctor, assisted by the intelligent devotion of the nurse. The comfort and the duration of disability of all others may be materially modified for good by careful study and wise individualization of our cases. A long list of permissible articles, from which selection can be made for different cases, and for the same case at different times under varying circumstances, can be given. That which I append makes no claim to completeness, but is meant merely to be suggestive and illustrative:

1. Milk, hot or cold, with or without salt, diluted with lime water, soda water, Apollinaris, Vichy; peptogenic and peptonised milk; cream and water (i. e., less albumin), milk with white of egg, slip buttermilk, kumyss, matzoon, milk whey, milk with tea, coffee, cocoa.

2. Soups: beef, veal, chicken, tomato, potato, oyster, mutton, pea, bean, squash; carefully strained and thickened with rice (powdered), arrowroot, flour, milk or cream, egg, barley.

3. Horlick's food, malted milk, carnipeptone, bovinine, somatose.

4. Beef juice.

5. Gruels: strained cornmeal, crackers, flour, barley-water, toast-water, albumin, water with lemon-juice.

6. Ice cream. Water ice.

7. Eggs, soft boiled or raw, egg-nog.

8. 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. Blanc-mange, wine jelly, apple sauce and macaroni.