Assuming a patient has satisfactorily passed through his fever, and his temperature is approaching the normal line, when is the first increase of diet to be made? Much must depend upon the circumstances of the individual case. Unless he is really hungry, there is no particular advantage in making any addition to the diet till the temperature is steadily normal. By "real hunger" is to be understood a genuine craving for food; that is to say, it is not enough for the patient to reply that he is hungry when asked. He must volunteer the information himself. If his hunger is real and all precautions to satisfy a false appetite have already been taken, some addition to his food may be allowed when his temperature is normal in the mornings, the evening readings being disregarded. Should his diet, up to this point, have consisted exclusively of milk and meat broths, with the few extras that may have been permitted in prolonged cases, it is obvious that, before he is allowed solid food, he must be content with semi-solids and " sloppy " materials. Benger's food or boiled bread and milk are usually my first additions, and the effect of even this slight increase of diet on the temperature of the patient should be carefully noted. If the morning temperature remains normal, the bread and milk is continued for two or three days, the amount given being gradually increased and a little well-made oatflour porridge being added to give variety. By this time the evening temperature has also frequently settled, but even if not another increase may be safely tried, always provided there has been no rise above normal in the mornings. At this stage the first solids may be given, a sponge biscuit or a small amount of light sponge cake being a quite suitable substance to experiment with. If this is tolerated, I am accustomed next day to allow a very small quantity of white fish. This should be boiled or steamed, and all skin should be carefully removed. The best fish for this purpose is whiting, but in hospital practice fresh haddock forms an admirable substitute. A very thin finger of bread, from which all crust has been cut, may be given with the fish. On the following day, always assuming the morning temperature remains steadily normal, a little thin bread and butter may be allowed at breakfast and tea time, the patient still receiving a reasonable quantity of milk at definite intervals, and beef or chicken tea being continued exactly as before. For three or four days this diet may be continued, the amount of food given being cautiously increased, and such additions as a little baked custard pudding or some well boiled milk-pudding may be permitted. Should the morning temperature rise above normal, it is wisest to go back to the fluid diet at once, until at least the cause of the pyrexia has been ascertained. It is quite possible, of course, that the cause may lie elsewhere than in the diet. Constipation, for instance, is often troublesome at this stage, and the temperature of the enteric convalescent, being extremely mobile, is very readily affected by it. Such complications, moreover, as phlebitis, otitis media, and superficial skin abscesses may supervene in convalescence and cause some degree of fever. In such instances it is rarely necessary to make much modification in the diet and, the pyrexia being satisfactorily accounted for, the appetite of the patient may be taken as a rough guide for the amount of food required.
Should, however, the addition of solids to the dietary leave the temperature quite unaffected, after a few days of steady increase in the amount of food given, a further step may be taken and the patient allowed a little of the breast or wing of a chicken. My patients, as a rule, receive this from three to five days after their first allowance of fish. With the chicken may be given a little mashed potato, which, indeed, I frequently allow to be added when the diet is still limited to fish. Chicken having been allowed, except for the addition of stewed fruit, the diet is kept well in hand till all chances of relapse are over, after which (say after a fortnight's normal temperature) there is no reason why meat should not be allowed in moderation. In moderation, indeed, success in the dieting of an enteric patient usually lies. As much variety of food as possible should be given, but at first only in small amounts.
It will be noticed that very little attention is paid to the evening temperature. As a matter of fact it cannot be regarded as a reliable guide. A temperature which is normal in the morning and swings up one or two degrees at night sometimes depends upon inanition. It is a "starvation temperature" and the longer one waits for it to settle the less likely is it to do so. Extra feeding often brings it down to normal in a couple of nights. A point of more importance to notice is whether the temperature is subnormal rather than normal. A case in which the temperature is steadily subnormal after the completion of the lysis seldom relapses. If, on the other hand, it runs along the normal line, as it is usually marked on clinical charts, there is a considerable chance of relapse. In the latter circumstance it is wiser to be moderate with the feeding and to advance the patient less rapidly, restricting him rather to the stage of fish and light farinaceous foods.
As to the effect of diet on the occurrence of relapses it is, I think, very problematical. An injudicious addition to the diet may cause a rise of temperature most undoubtedly, but such a rise will subside on the removal of the cause. In some patients, especially in those who have been very rigidly dieted, the first addition of solid food occasionally causes some elevation of temperature, possibly from a reflex cause. To others again the first allowance of solids is such an event that their excitement is quite sufficient to account for the subsequent pyrexia. But these rises of temperature are not repetitions of the original fever. In other words, they are not relapses. They are due merely to local irritation or to nervous excitement as the case may be. They are also often due to constipation. The fact that, in cases which relapse, the spleen remains markedly enlarged during the apyrexial interval would point to the cause of relapses being connected with that organ, and it may be added that relapses occur at least as frequently in those cases which are dieted rigidly as in those which are fed liberally. This is shown by the fact that the percentage of relapses in a series of 397 consecutive cases of enteric fever, who were fed less liberally and less early in convalescence than is suggested above was 5.79, whereas out of a subsequent series of 758 cases, whose diet was on the exact lines I have indicated, only 3.95 per cent relapsed. Both series were treated by myself in the Edinburgh City Hospital. The fact that the general treatment differed considerably is of little importance. The figures go far to show that relapses are at least not increased by early and liberal feeding in convalescence, as do also those published by Kinnicutt, which are quoted later in this article.