In our treatment of any of the acute fevers it is necessary to keep in view the conditions which may complicate its course and convalescence. Were it not for this there would be but little to say respecting the diet of scarlatina, and, even as it is, many take the view that this fever may be dieted on the same lines as any other acute infection. For many years physicians in planning a diet for scarlatina patients have been influenced by the comparative frequency with which acute nephritis and albuminuria are liable to occur in its convalescent stage, and many of the dietaries suggested have been therefore devised to act as a prophylactic measure against this particular complication. As in the case of the other fevers, I propose to state briefly the method of dieting which I am personally in the habit of employing. Thereafter diets which are more liberal or more restricted may with advantage be discussed.
This stage is in the majority of cases brief, seldom lasting more than a week in the simple forms of the disease. Any elaborate or complicated diet would appear, therefore, to be out of place, as the patient may be expected to maintain his strength quite satisfactorily on a fluid regime. During the first twenty-four hours of the fever vomiting is so frequent a symptom that the patient may well be left alone. Later, after the appearance of the rash, milk is, as a rule, quite sufficient. The milk should be given with the same precautions as were indicated in the section on enteric fever. As the temperature falls the amount given may be increased gradually if the patient takes it well and is at all hungry. I am not accustomed to give meat broths at this stage. If given at all they should be weak. Water should be supplied freely to the patient, and there is no objection as a rule to alkaline aerated waters should he prefer them. Fruit juices to flavour the drinks given are often very refreshing and their use may be encouraged. Weak tea may also be allowed in moderation.
In the more prolonged forms of the fever, in septic scarlatina (scarlatina anginosa) for example, it may be necessary to allow somewhat more than a purely milk diet. Arrowroot and other starchy foods, thin oatmeal gruel, Benger's food and other similar preparations may all be given, as may well-stewed fruit if it can be swallowed. The difficulty indeed often is, in the septic form of the fever, for a patient with an acutely inflamed and ulcerated throat to swallow anything but fluids. Occasionally fluids themselves cannot be swallowed in sufficient quantity to adequately nourish the patient. In such cases nasal feeding must be resorted to, and its systematic use often has a very beneficial effect on the condition of the mouth and fauces which, being thoroughly rested and also relieved from the fermentative action of food substances clinging to them, sometimes clean up with remarkable rapidity. Broadly speaking, I consider the use of meat extracts and beaten-up eggs undesirable in the acute stage of scarlatina, but there is no need to hesitate to prescribe either should the patient not appear to be adequately supported by the above diet. Stimulants, again, are usually undesirable, but in this type of the fever often necessary.
The malignant or toxic type of scarlatina offers few opportunities for dietetic treatment. Its course to a fatal termination is usually rapid, and vomiting is so often persistent that we are frequently reduced to rectal feeding. As, however, diarrhoea is also present in many cases, even this may be found to be impossible. Everything should be done to force fluids on the patient and to favour the elimination of the toxins. If water is vomited saline injections by the rectum, under the skin, or into a vein may occasionally save an apparently hopeless case. Stimulation, preferably with brandy, or perhaps champagne, should be very freely resorted to.
When the temperature of a simple case has reached normal, the milk diet may be supplemented by farinaceous foods. In the morning thin oatflour porridge with plenty of milk. A little later a second breakfast of tea and bread and butter. At dinner time, rice and other milk puddings, stewed fruit with plenty of milk, and, if enjoyed, milk soups flavoured with vegetable juices. In the afternoon, tea with plenty of milk, bread and butter and jam. At supper time bread and milk, or porridge with milk, and a slice of bread if desired. A good allowance of milk, a pint at least, and preferably more, should be taken in the twenty-four hours. Water should also be supplied freely. If febrile complications, such as arthritis, should occur, this diet may still be given if the patient has sufficient appetite.
There is no necessity in my opinion to increase this dietary till the period at which nephritis occurs most frequently is safely passed. Exceptions can be made in the case of adults, fish being allowed from the commencement of the third week. Otherwise it will be withheld till the middle of the fourth, when it may be allowed, as may white meat, chicken or rabbit, meat soups and, a little later, meat and eggs. In young children, eight years and under, it will seldom be necessary to give more than white fish. Potatoes may be given at any time in the stage of convalescence, as may fresh fruit. I am far from saying that a much more liberal diet might not be given with perfect safety, as indeed the practice of many authorities proves, but the above appears to me to be quite sufficient and is not likely to overtax the kidneys.
Those, on the other hand, who believe that the kidneys may safely be disregarded and that the occurrence of nephritis is in no way influenced by early feeding, are more liberal in their supply of food to the patient. Foord Caiger, holding that there is no evidence that nephritis has ever been induced by the administration of a diet containing a moderate amount of nitrogenous food, gives a quite liberal diet, even in the acute stage. Soup, beef-tea, and beaten-up eggs are all permitted in the febrile period. Solids are given as soon as the temperature is normal, and the condition of the patient's throat permits. Bread and milk, custard, milk puddings, lightly-boiled eggs, and thin bread and butter with the crust removed are the first additions to the diet. In two or three days he extends this diet so as to include fish, poultry, and meat. A similar dietary is recommended by Goodall, and it appears that meat is usually given comparatively early in the great fever hospitals of the Metropolitan Asylums Board. Green vegetables are recommended in the early days of convalescence. The value of fruit is also insisted on.