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, on the following day a very small quantity of white fish may be allowed. This should be boiled or steamed, and all skin should be carefully removed. The best fish for this purpose is whiting or sole, 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. A good dietary for this stage is presented in the following diet sheet: -

Diet Sheet IV. Full Convalescent

6 A.M. - Tea with milk, bread and butter.

8 A.M. - Oatflour gruel, with milk and cream. 10.30 a.m. - Milk with half egg, beaten. 1 P.M. - Soup (strained), 10 ounces.

Fish, or chicken.

Milk-pudding and stewed fruit, or jelly, or custard; eaten with cream. 4.30 P.M. - Tea, boiled egg, bread and butter, jelly, sponge cake.

7 p.m. - Cornflour, arrowroot, or semolina, made with milk; eaten with cream, bread and butter. 10 p.m. - Hot beef-tea.

Should the morning temperature rise above normal, it is wiser 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 to 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. Patients, as a rule, are ready to begin this from three to five days after their first allowance of fish. With the chicken may be given a little mashed potato, which may be added when the diet is still limited to fish. A little stewed fruit may now be added. This diet is maintained till all chances of relapse are over, after which (say after .1 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.

Value Of Water-Drinking In Typhoid Fever

Thirst should be assuaged by the drinking of a large amount of plain water, from 4 to 6 pints of water being given daily. In addition to assuaging thirst, an abundance of water-drinking promotes elimination of the toxins. When an insufficient amount of water is taken, the tongue gets very dry, even when the mouth is being carefully attended to. Aerated waters should be avoided, as tending to induce flatulence. Imperial drink (p. 276), or an acidulated drink made with a few drops of hydrochloric acid and a little syrup of lemons, are also of value in allaying thirst Weak tea made with milk is permissible, except in cases troubled with insomnia.

Dietetic Treatment Of Complications

This has already been incidentally referred to, so far as regards the troublesome complications of constipation, diarrhoea, and meteorism. In the treatment of constipation the addition of fluid magnesia to the milk, and of beef-tea to the diet, will prove serviceable; diarrheca may be combated by the use of lime-water as a diluent in place of plain water. If this does not suffice, the milk should be peptonised, and the amount given should be considerably reduced. Beef-tea should be withdrawn from the diet until the diarrhoea has disappeared. Meteorism is not a common complication in cases that are judiciously fed. It may be combated by peptonising and pancreating the milk, and by making more use of beef-tea and chicken jelly. If necessary, the amount of milk may be for the time reduced, or skimmed milk or whey may be substituted.

Hamorrhage is treated by starvation for thirty-six hours, and thereafter the administration of teaspoonful doses of concentrated foods every three hours. Peptonised milk and chicken jelly are the best foods for early administration. If no return of symptoms develop, the amount of these are gradually increased, and also the frequency of administration. At the end of the third day the patient may, in favourable cases, be getting a diet consisting of 10 ounces of peptonised milk, 1/2 ounce of chicken jelly or meat juice, administered in small amounts every two hours. If this is well borne, the diet can be increased daily with fair rapidity.

The question of the use of stimulants in cases of haemorrhage is a very important one. They should be withheld unless the condition of the patient is one of great collapse, with an extremely feeble pulse. Under these circumstances brandy should be administered in not more than teaspoonful doses at frequent intervals, the effect of this being very closely watched, so as to avoid risk of overstimulation with a recurrence of the bleeding.

In the event of perforation occurring, the dietetic treatment for the first few days after operation should take the form of rectal alimentation. Injections of saline, 8 to 10 ounces, with the addition of dextrose, are of special value. Thereafter oral administration may be begun, a start being made with very small quantities of peptonised milk, chicken jelly, raw-meat juice, given every hour.

Other Systems Of Feeding

The system of feeding already outlined may be taken as the one generally recognised as the most suitable for the feeding of typhoid fever cases. Reference must, however, be paid to other systems which have found favour with recognised authorities.

Liberal Diet, With Solid Food From The Outset

This treatment was introduced by a Russian physician, Bushuyev. His method is to allow solid food to all who can take it, from the moment they come under observation. The following is the dietary suggested by him for the acute stage: -

7 a.m. - Tea, with a roll.

8 a.m. - Oatmeal, barley, or wheat liquid porridge, with butter (about 13 fluid ounces).

9 a.m. - One or two boiled eggs, hard or soft as the patient prefers. 10-11 A.M. - A glass (about 7 ounces) of milk, a roll, half a cutlet, or a piece of boiled meat. 12-12.30 P.M. - A plate (about 7 ounces) of chicken soup, or ordinary soup, and a cupful of jelly. 3 P.M. - Tea, with a roll. 6 P.M. - A cup of chicken or beef-tea, semolina pudding or milk, and a bit of chicken. 8 p.m. - Milk, with a roll. During the night - Coffee or tea, with milk, two to four times; coffee with cognac.