Patients also need to be given an occasional drink of water. Unless specially instructed, nurses frequently neglect this. They wait for the patient to ask for a drink, and he is often too dull to do so. Lemonade is craved by many and is harmless. Tea and coffee may be permitted in small amounts when they are desired. Coffee is decidedly useful in extreme cases when the heart is weak or failing. It should be given then as a strong decoction. A half-pint may be allowed daily. The simpler diet of milk, or milk and bouillon, is to be preferred, however, except in those rare cases when a variety seems necessary to satisfy a patient's cravings or caprice.

Fruit-juices, such as orange-juice and grape-juice, and jellies are relishes that are not only harmless, but mildly nutritious, and are much enjoyed by fever patients.

Drinking copiously of liquid foods and water increases tissue oxidation, but does not increase disintegration; therefore elimination of waste-products becomes more perfect. By introducing much fluid into the circulation, waste-matters are washed from the tissues and rapidly carried to the organs of excretion. It also lessens the concentration of the blood, which is considerable during the first half of the course of typhoid fever, and therefore prevents exosmosis from the tissues. Elimination by the kidneys is increased because blood tension is greater. The noxious matters in the blood and lymph are diluted and become less irritating to the nervous system and emunctories. The typhoid state is consequently less pronounced when fluids are drunk freely, and the kidneys, liver, and muscles are less likely to degenerate.

In the worst cases it is often impossible to give enough fluid by the mouth to obtain these desirable results. Water and food must then be given by the rectum. Water can be given also subcutaneously with advantage. For this purpose, physiologic saline solution is to be preferred, and necessary precautions must be taken for aseptic injection.

It is not safe to give solid food until a normal temperature has been maintained a week or ten days and the patient's stools have lost the typhoid characteristics. My own rule is to wait a week in cases of average severity, but to try a soft-cooked egg by the fourth or fifth day, and a little milk-toast by the sixth. After this an approach to solid food can be made by using custards, corn-starch, and rice pudding, finely chopped or scraped meat, and creamed codfish; then dry bread with meat-juice or fruit jelly; the breast of pigeon or chicken, a chop, mashed and baked potato. These changes in diet must be made slowly and tentatively. If, however, any rise of temperature is noticed, it is best to return to the liquid diet, or at least lessen the amount of food eaten. If recovery goes on uninterruptedly during the first week after beginning the change of diet, there is little danger of harm from solid food.

The following menu illustrates the changes of diet which may be made when the change from liquid to solid foods is started:

First day, soft-boiled or poached egg.

Second day, milk toast, chicken or mutton broth.

Third day, scraped beef, boiled rice, wine jelly.

Fourth day, cornstarch or arrow-root, milk toast, eggs or scraped meat or custard and fruit jelly.

Fifth day, chicken or squab or oysters, baked potato or rice, apple sauce or fruit jelly or jelly, etc.

Sixth day, in addition to milk and other foods previously permitted a somewhat larger quantity and variety can be given.

Although the dietetic management just described is the one admitted by most eminent clinicians to be the best in typhoid fever, attention must be called to the usage of a few who feed their patients much more generously. They give the liquid foods mentioned, but also gruels, eggs, minced meat, boiled rice, milk toast and similar foods. They attempt to give food which will produce 2000 to 3000 calories. In exceptional cases I have used this diet but it does not seem to meet the indications of the disease as well as the other.

Some relapses certainly date from the time of feeding patients too much food or food too difficult to digest, and they are generally supposed to be thus caused. Improper feeding, however, is not the chief cause of relapse; yet it may be a factor, and is an avoidable one. While the safest rule as to the time of changing from an exclusively liquid diet is that just stated, rare cases are met with in which a low fever persists for many days after the bowel movements have become normal and typhoid symptoms have disappeared. This is especially liable to occur in patients who are greatly debilitated from a prolonged course of fever and who have become greatly emaciated. This fever is frequently spoken of as a fever of inanition. To such patients food must be given more generously and be of a semisolid character even before the fever disappears. Indeed, the fever will cease sooner if such food be given than if it be withheld. In such cases the temperature is usually normal, or almost so, from about midnight to midday. This is the time when semisolids are best given. During the hours of pyrexia the food should be liquid.

Meteorism is sometimes due to milk indigestion or to carbohydrate indigestion, but often more to relaxation of the intestinal wall and consequent imperfect expulsion of gas. A temporary change from milk to broths fortified with somatose or egg-albumin or the omission of carbohydrates if they have been used, helps. Turpentine stupes, enemata and an ice-bag usually do more good. The administration of intestinal antiseptics are of little avail.

If a hemorrhage occurs complete intestinal rest should be insured by stopping the administration of foods for twenty-four hours at least. A little water or ice can be given. A 2 per cent, solution of gelatin slightly acidulated with lemon and kept cold can also be given partly to lessen thirst and partly for the styptic affect of the gelatin. When the administration of milk is again begun, it should be fed in spoonfuls every one or two hours and very gradually increased in amount. Complete bodily rest should be assured. Opium is often needed to stop peristalsis. An ice-bag upon the abdomen is also a help.

Alcoholic beverages were formerly used with great freedom in all fevers. During the last few years they have been employed less and with more discretion. I have already so fully discussed their physiologic action and character that it is necessary here only to refer to the former chapter devoted to them, and to repeat that they should be avoided in the absence of positive indications for their use.