Dec., 1938] EDITORIALS 745

Indian Medical Gazette

DECEMBER

DIET IN TYPHOID FEVER

' Feed a cold and starve a fever \ This is a

popular fallacy that has been current since the days of Hippocrates, who gave his fever patients wine and thin barley gruel only; it is a fallacy that was shared by the medical profession until less, than 100 years ago. In fact towards the end of the Dark Ages, when after that long period of quiescence physicians' minds again began to work, their first achievement in this connection was the invention of a false pathology to justify the Hippocratic teaching, and it was not until the middle of the last century that certain physicians, ignoring the half truths of the very incomplete pathological knowledge of their day and basing their teaching on clinical experi- ence, reversed the teaching and 1 fed their fevers This practice has been fully justified by sub-

sequent scientific observation; two fallacies have been exploded, namely, that free administration of food tends to raise the temperature of a febrile patient, and that the febrile patient does not absorb nourishment from the food he is "given. It has been proved that ordinary light articles of diet are digested and absorbed as readily by the febrile as by the healthy patient, and that their absorption plays no part in raising the temperature.

It has been shown that the destructive effect of the toxins produced in fevers falls on the

proteins; one school of thought argues from this that nitrogenous substances should therefore be given to replace this loss, another that the organism is already embarrassed by an excess of waste nitrogenous products and that proteins must therefore be withheld; probably neither ls entirely right, but the present tendency is more in favour of the latter view and an attempt

made to replace the lost proteins as far as

Possible, not by the giving of an excess of Proteins but by combining easily assimilable

Protein, e.g., of milk, with other substances that spare proteins, namely carbohydrates and fats; fats often have a nauseating effect and the febrile patient is unable to take them except in small quantities, so that in actual practice the diet is often reduced to milk and carbohydrates. Whilst the practice of 'feeding fevers' in

general was adopted much earlier, it does not seem to have been applied to the treatment of typhoid fever until early in this century; again a misinterpretation of pathology was respon- sible. The pathologist exhibited the wasted

J^testine with the shallow typhoid ulcers and ?eir tissue-paper-like bases, one of which had

given way and brought the patient to the post- mortem room. It was a matter of surprise that

the others had stood up against the passage of even fluid food and the normal intestinal move- ments. The deduction is that the less food that reaches this part of the intestine, the greater are the chances that the base of the ulcer will survive; so the next patient is given milk whey and glucose, and is lucky if he gets a thousand calories a day. It has been estimated that in typhoid, metabolism is increased by 40 per cent above the normal, so that the average male adult patient's daily requirements amount to

about 4,000 calories and, as he is only getting 1,000, he has to make up the balance first by living on his own fat, which is soon exhausted, and then on his muscles, including his intestinal muscle, which would otherwise have formed a

firm base for a typhoid ulcer, or good support for an intestinal arteriole that has been exposed by the separation of a slough. This is not by any means all theory, and

figures have been produced which show quite clearly that in practice the chance both of haemorrhage and of perforation are reduced considerably when a high-calorie diet is given. The high-calorie diet is the routine in the treat- ment of typhoid in the United States and to a

less extent in Great Britain, but in India the

practice does not seem to extend beyond the

large hospitals, and it is not always followed in these. This is in some ways surprising as

physicians in this country are usually very ready to follow any new and successful development in other countries?and not infrequently to give a lead. The first and most important cause is the fact that in India professional nursing is almost non-existent outside the large hospitals, so that, if the patient is treated in his own home, as he is ninety-nine times out of a hundred, his relatives or friends undertake the nursing. Another cause is the physician's lack of author- ity in the Indian household, which is a most

striking social phenomenon in this country. The father of a household will not hesitate to pay large fees to get the best medical opinion, he will listen most carefully to the doctor's opinion, and he will have all his prescriptions made up, but quite frequently these are never given to the patient. It is not surprising that parenteral treatment is so popular amongst medical practi- tioners in India; when he has given an injection the physician does know that his patient has had at least one dose of the drug. In the matter of diet he is powerless; if the mother of the household has decided that typhoid fever needs starvation, no amount of quotation of authorities nor expositions on pathology will convince her to the contrary. Further, the patient will be on her side as he has little inclination to take any food, and even in hospital practice it is often

very difficult to persuade a patient to take the diet prescribed. The figure 4,000 calories, that was mentioned

above, was based on European and American standards, and of course it would be wrong to

apply it to the Indian patient, but we may say

746 THE INDIAN MEDICAL GAZETTE [Dec., 1938

that he should receive a diet of at least 20 calories per pound of his expected weight, calculated from a height-and-weight table, not

of his actual weight, as, if he is already- emaciated, his requirements are actually greater than if he is fat. This will put the require- ments of the average Indian male adult at

between 2,000 and 3,000 calories. As to how this diet is to be made up, one cannot dogmatize; not only will there be caste and religious customs but personal prejudices and idiosyncrasies to be considered. In most instances, milk will be the important item in the diet, but, on the basis of 2,500 calories, more than 6 pints would have to be taken, which is usually impossible. Many patients find it difficult to take ordinary milk and in these cases citrated or lactic acid milk

may be better tolerated; variety can be intro- duced by substituting Horlick's, Ovaltine, or

some other proprietary milk preparation. Lac- tose and dextrin are valuable for piling up the calories, as they are not so likely to give rise to fermentation as is glucose, and the former, not being so sweet, will be taken more readily by the patient. Whilst soups generally contain little nourishment, a well-made chicken broth will contain at least as many calories as the same quantity of milk, and, if caste considera- tions allow, makes a pleasant change. It is not essential that the diet should be entirely fluid when it enters the mouth; such things as biscuits, rusks and bread and butter are as fluid as milk

by the time they pass through the pylorus. A little solid food of this kind will help to keep the patient's mouth in better condition. Eggs beaten up with milk can be included in the fluid

diet, or given lightly cooked as a solid sub- stance. Potatoes mashed with butter, vegetables and fruits strained through muslin to remove the coarser fibres that would form a residue, and even rice similarly treated will add variety, more calories, and vitamins. Whatever diet is given it should be carefully scrutinized to assess its vitamin content and the missing factors provided medicinally. To persuade a patient to take his full quota

of calories will often tax the good qualities of the nurse to the utmost extent, and to give him this amount of nourishment without producing diarrhoea, vomiting, tympanites, or other un-

favourable symptoms will need not only skilful nursing but daily attention to the diet chart and wise prescribing on the part of the physician. Typhoid fever in Indians is not as a general

rule such a severe disease as it is in Europeans, but six weeks' starvation alone will reduce a

patient's strength very considerably and neces- sitate a long convalescence. It should be the

physician's aim to see that the patient leaves his bed at the end of his typhoid attack

weighing as much as, if not more than, when he entered it. This may be difficult but it is far from impossible and it is an ideal that should be easier to achieve in this country where milder, less toxic attacks of typhoid

are the rule, in hospital practice at any rate. In the Indian home we shall not alter the traditions of generations within a few months, years, or even decades, but on the other hand we should not acquiesce silently in a practice that we know to be against the best interests of our patient. Above all it is by the example of the results achieved in hospitals that in time we may hope to make the principle of '

feeding a

fever ' applicable to typhoid, even in the Indian home.