Milk, however, still remains, in my opinion, far the best staple food for the enteric patient, and all that is necessary to render its employment perfectly safe is to lay down sufficiently rigid rules for its administration. The first of these is that on no account is it to be used to quench the patient's thirst. Rather is it to be regarded as the solid part of his food, water being supplied freely when he requires it. Secondly, the milk should be supplied in measured quantities and at regular intervals. Each supply should be looked upon as a definite meal. As regards the length of the interval between these meals I am accustomed to make it two hours. In many cases, no doubt, a large amount of milk every three hours would be equally satisfactory, and at night it will be often found advisable to prolong the intervals so as to disturb the patient's sleep as little as possible. It would be imprudent, however, to leave the patient without nourishment for more than four hours, even at night. As regards the amount of milk given, I am convinced that the power of milk digestion in the average patient is much overrated. I never start a case on more than 3 oz. every two hours, that is to say, somewhat under two pints daily. It is seldom of advantage to increase this amount beyond 4 or 4 1/2 ozs, two hourly. Personally, I make 4 oz. my maximum amount, and do not often exceed 3 1/2. Larger quantities are often very imperfectly digested.
The milk is always the better for being diluted, and for this purpose hot water may be added in the proportion of 1 to 4, or 1 to 3, of milk. The warmth of the mixture assists the digestion, which is also aided by the dilution, the curd being probably less firm. If more drastic methods of moving the bowels are objected to, fluid magnesia may be added to the water used as the diluent. Limewater is also very useful in this connexion, should there be a tendency to diarrhoea.
Another rule of great importance is that the portion of milk must be consumed within a reasonable limit of time, certainly within a quarter of an hour. On no account is it to be allowed to stand at the bedside. It is very necessary that the stomach should have an adequate rest before the next meal.
As long as milk is given as the staple article of diet, it is highly desirable for the stools to be carefully examined daily. The presence of undigested curd, whether in large masses or small flakes, proves that either more milk is being given than the digestion can tolerate, or that proper care is not being exercised in its administration. The deduction of half an ounce from the two hourly allowance is often sufficient to cause a complete disappearance of curds from the motions, and as a result to check that looseness of the bowels so often occasioned by the presence of undigested food in the intestine. If it is found that milk is badly tolerated by the patient, even when given carefully, an admirable substitute may be found in whey.
While many patients are quite sufficiently nourished by milk alone, it is advisable to supplement such a diet by the use of beef tea, meat extracts, and similar preparations. As regards the first, it is well to wait till the patient has been twenty-four hours under observation. Should diarrhoea be present, the use of hot beef-tea would only aggravate it; should there be blood in the stools, anything tending to loosen the bowels is to be deprecated. On the other hand, if after a short period of observation it is found that the patient is not suffering from diarrhoea and that the condition of the stools is satisfactory, the use of one or other of the meat broths is of distinct advantage. A purely milk diet is terribly monotonous, and a reasonable allowance of chicken or beef-tea is much appreciated by the patient, even though its food value may be very small. These preparations should be given well salted. They form, indeed, an admirable vehicle for the salt which is so much craved for by patients who are kept upon an exclusive milk diet. Much of the hunger, in fact, which is so characteristic of enteric fever is probably due to the deprivation of salt which a strict milk regime entails. The first articles of food desired are usually those which have a salt flavour, such as ham, kippered herrings, and the like. And this " false appetite " often disappears completely if a sufficiency of salt is added to the chicken or beef tea. I prefer this to salting the patient's milk which, however, may be done in moderation if it is considered undesirable to use the meat preparations. Taste is often so blunted in enteric fever that an amount of salt, which would be nauseous to an individual in health, is readily tolerated. Still, it is necessary to take the greatest care not to disgust the patient with milk if he is to depend on it as his chief article of diet.
It has been said above that the actual food value of beef or chicken tea is probably extremely small. They are much more useful as stimulants and hypnotics. Professor Wyllie, to whose teaching and example I owe this particular system of dieting, was accustomed when at the Edinburgh City Hospital to recommend that the daily allowance of beef-tea, usually a pint, should be divided into three equal portions, the first of which, given at midday, broke the monotony of the constantly repeated milk, the second, given very hot at night, assisted the patient to get to sleep, and the third, given in the early hours of the morning as a stimulant, helped to tide the patient over the period of his greatest depression. I am certainly convinced that by a rational use of hot chicken or beef-tea in this manner, hypnotics and alcoholic stimulants can be often dispensed with. The distinct laxative effect of beef-tea, moreover, is occasionally very useful.
In cases of diarrhoea it may be found advantageous to make use of the many meat extracts which are nowadays available, or to employ raw meat juice. As a rule, the former preparations are the most convenient. They should be given cold and mixed with a little water. I usually prescribe bovinine, in the nutritive value of which I have a very firm belief. Valentine's meat juice is also admirably tolerated by patients with severe diarrhoea, and a very pleasant and sustaining preparation is Brand's chicken jelly, which is the most agreeable of the three from the point of view of the average patient. There is a wide choice of meat extracts, and the practitioner will do well to employ the one in which he has reason to feel most confidence, always provided, of course, he is satisfied that it will not aggravate the diarrhoea.
Through the whole of the acute stage much may be gained by the careful inspection daily of the patient's mouth and tongue. The toilette of the mouth is most important and if, when this is carefully attended to, the tongue still remains very dry, the suspicion should be aroused that fluids are not being given in sufficient amount.
While in my experience the average enteric patient maintains his strength satisfactorily on the limited diet outlined above, in certain cases it will be found advisable to supplement it. When the fever is very prolonged and there is excessive wasting, such substances as plasmon, somatose, sanatogen and similar preparations may be added. Half an egg beaten up in a little milk with a teaspoonful or two of brandy can be given twice in the twenty-four hours. Albumin water may also be found useful. A small amount of very well boiled rice may be added to the beef or chicken tea allowed to the patient. Jelly with various fruit or wine flavourings may also be safely employed to supplement the diet. This greater liberality is also advisable in cases of relapse, especially if the first attack has been at all prolonged. Wasting is, of course, to be expected in every case of enteric fever but it may unquestionably be allowed to go too far. Any of the above additions to the dietary may also be made in cases where the hunger of the patient appears to remain unaffected by an increase in the amount of milk given, or by the addition of more salt to the food allowed. This is particularly the case during the stage of defervescence.