There is no doubt that theoretically much is to be gained by giving a liberal and varied diet. When we consider the extreme wasting which often occurs, even when the patient is taking freely all the fluid nourishment which we are accustomed to consider desirable for him, the reflection is forced upon us that the heart and intestinal walls may be suffering almost equally with the muscles. The bowel wall of a patient who has succumbed to a prolonged fever is often found at the autopsy to be extremely thin. Is it possible that by restricting unduly the food supply of the patient we are weakening the resistance of his bowel wall to the ulcerative process? I am convinced that the use of solid food early in convalescence does much to shorten the duration of the case. Does the more liberal supply of food at this period help to promote the healing process in the ulcerated intestine as well as to repair the waste caused by the fever? That it prevents to some extent such sequelae as periostitis, abscesses, and otitis media is certainly probable. If such additions are justifiable from the moment the patient's temperature touches the normal line, would they not be equally so at an earlier period, say at the commencement of the lysis when he is beginning to show-signs of returning appetite?

The only argument against giving solid food throughout the fever, say the advocates of a mixed diet, is the inability of the patient to take it. Other objections are mainly theoretical, such as that it is liable to cause such accidents as perforation and haemorrhage, or that it increases the tendency to relapse. We have seen above that early solid feeding in convalescence has little or no influence on the frequency of relapses. There is therefore no reason to believe that relapses should be more frequent in cases which have been fed on a mixed diet during the acute stage. It is possible, however, that such a treatment might prolong the original fever, but this, according to the supporters of solid diet, is not the case.

Theoretical Objections To Milk

On the other hand, although most physicians will agree that milk is the most convenient food to use during the acute stage of enteric fever, it is not altogether an ideal diet. The patient who is fed exclusively upon it gets more fat than is necessary and probably too little protein. The carbo-hydrates are certainly insufficient from the theoretical point of view. It is said, and no doubt so far as laboratory experiments go the statement is correct, that to make good the waste caused by the increased metabolism in such a fever as enteric it is necessary for the patient to take 8 oz. of milk every two hours. Such an amount it is obviously impossible to give, and if, therefore, the waste is to be considered the milk must be supplemented by other articles of food.

It has also been suggested that, as milk is extremely deficient in iron salts, the prolonged anaemia which often follows enteric fever may be in part due to the fact that a milk diet is used. Digestion, moreover, is rendered more easy by the reflexes excited by the mastication of solid food in the mouth, and on the other hand suffers when the food given excites disgust, as the long-continued monotony of a milk diet is apt to do. Milk, again, becomes a semi-solid in the stomach and therefore cannot properly be considered as a fluid food. The curds are not always easily broken up and digested in the small intestine. We have seen that this difficulty can, as a rule, be obviated by proper care being taken in its administration, but at the same time we must admit that the undigested residuum of milk is often most irritating to the bowel. Again, it has been asserted that milk acts as an admirable culture medium for the typhoid and intestinal germs, and that its employment should be limited on that account. This objection is probably slightly more valid than the identical one which has been raised with regard to the use of beef-tea, which can leave practically no residuum for the benefit of the intestinal bacteria.