As the appearance of the whoop is usually the first certain sign of the disease, the question of diet in this prodromal period needs little or no discussion. It is only seldom that patients in this stage come under our observation. If there is any fever a fluid diet is indicated, and this should be of as bland and unstimulating a character as possible. Milk, supplemented occasionally by meat broths, is all that is required.
It is when this period of the disease commences that we have seriously to consider the best means of feeding the patient. We have often two difficulties to contend with. Firstly, a paroxysm, coming on shortly after food has been given, is very liable to empty the stomach in the act of vomiting, which so frequently follows the whoop. Secondly, some children learn by bitter experience that the giving of food excites the cough, and as a result firmly resist any attempt made to feed them. To force food upon such patients usually results in their acquiring an unpleasant habit of deliberately rejecting from the stomach whatever is given.
It is not only, however, the risk of the food being vomited or refused which has to be considered. We must also recollect that gastric irritation, whether from overloading the stomach or from unsuitable food, undoubtedly excites the cough and, therefore, whatever is allowed must be given only in small quantities, and must be also very digestible. The stage of the paroxysm is, moreover, often so prolonged and so apt to exhaust the patient, that it is highly desirable to supply a liberal amount of nourishment, in order as far as possible to prevent the wasting, which is frequently a striking feature. In hospital practice, particularly, liberal feeding may be of paramount importance from the very first, as the majority of patients have suffered from much vomiting and from improper dieting before admission. The difficulty of giving them sufficient food is made no easier by the fact that their digestion has often been temporarily ruined before they come under observation.
There is, of course, a clear distinction to be drawn between children of different ages. Children of over five years of age rule, not difficult to feed. They are able to run about and often enjoy a healthy appetite. Unless they have been debilitated by a complication or by previous illness, they are perfectly capable of assimilating an ordinary light diet. I find in hospital practice that the admirable rule laid down for feeding in whooping cough, namely, to feed immediately after a paroxysm so as to allow time for digestion before the next spasm*, is impossible to carry out for all cases, unless a very large nursing staff is employed. When a fairly liberal diet, including a considerable proportion of cooked food, is given, such a method is impossible for a large number of patients. Even if an otherwise healthy whooping cough patient vomits the greater part of his dinner at once, he is usually perfectly ready to take it over again and retain it, if he is given the chance, as he should be. All children, then, who are able to be out of bed and who are over two years of age are allowed ordinary meals as in health, suitable to their age, and usually consisting of white fish, potatoes, occasionally minced meat, eggs, milk puddings, oatflour-porridge, and bread and butter. As long as the patient does not appear to be losing weight, and if the paroxysms are not unduly frequent or severe, the fact that the food is to some extent vomited, is a matter of very small importance. In private practice, where it may be possible for a nurse to devote her whole time to one patient, even in these sthenic cases the meals may be so arranged as to be given just after a whoop, as the interval between the paroxysms is often fairly definite. In this way some loss by vomiting may be avoided.
If, however, the case is more severe, the greatest care must be taken. It may be found, for instance, that the paroxysms are exceptionally frequent, and that a large proportion of the food ingested is vomited. Or the patient may appear to be losing weight and, perhaps, is not properly assimilating the food which he retains. In such cases, and in the prolonged broncho-pneumonias which are so frequently the cause of death in this disease, it is wiser to restrict the food to fluids and to give small quantities at frequent intervals, if possible, just after the whoop. A certain amount of this is usually digested, even if the vomiting with the next paroxysm is severe. I usually feed my patients chiefly on milk, often given with lime-water to correct any gastric acidity, and on small amounts of meat juices or extracts. Malt foods appear to be sometimes of advantage, and most of the children take Benger's food and other similar preparations well. The milk is always peptonized in the worst cases, and occasionally albumin water is added. In the less severe cases, milk puddings and starchy foods may be given, but as Eustace Smith points out, anything which is liable to cause fermentation or acidity is better avoided. Under this heading he classes farinaceous puddings, jam and fruit, all of which are harmless enough in older children, and mild cases, but are certainly better dispensed with in the type of case we are at present discussing. It must be remembered that gastric disturbance may do much to curtail the short snatches of sleep which such patients enjoy between the spasms, and so increases the nervous irritation which is so marked a feature in a bad case of whooping cough.
Individual cases may present very marked differences. Trousseau held that solid food was better digested than liquid, and occasionally even in severe cases this dictum may be remembered with advantage. I seldom, however, allow solids in a really bad case, whether pyrexia is present or not. In cases of moderate severity, if solid food seems to make the patient worse, soft solids may be used, such as porridge, rusks or sponge biscuits soaked in milk, bread and milk, and so on. Dry, solid food which may leave irritating crumbs in the fauces is very liable to excite the cough. Again, in the worst cases, if milk is not tolerated, it is always worth while to make a trial of whey. This is often most useful in infants.
If the patient refuses food altogether, everything should be done to persuade him to eat, and I often am willing to tempt such a child by allowing him anything in the way of food that he fancies, even if the article demanded does not appear very suitable. Rectal feeding is so unsatisfactory that we should try everything possible before resorting to it. Occasionally, however, it is our only resource. As regards the dieting in broncho-pneumonia, which should, generally speaking, be fluid, I have noticed, as after measles, that treating the patients in the open air makes them much easier to feed, a remark which, after all, applies to all cases of whooping cough. The disease is, in my opinion, far too frequently nursed in close rooms and artificial atmospheres, and under such conditions the difficulty in inducing the patient to take sufficient nourishment, always great, will be appreciably increased.