In a case in which care has been taken with the dieting it is unusual for troublesome diarrhoea to occur. On the contrary, this symptom usually subsides when the patient is fed suitably. Occasionally severe diarrhoea may persist, or may indeed even supervene in a properly treated case. If the patient is having beef or chicken tea these should be at once stopped. If any substitute for these is desired, raw meat juice or one of the patent meat extracts may be given. The milk should be boiled and diluted with lime water instead of with water alone. If this is insufficient to check the condition the amount of milk should be considerably reduced, and it may be peptonized or pancreatized. If whisky is being given it should be withdrawn and brandy substituted. Again, in cases of meteorism much may be done by reducing the amount of milk and by peptonizing it if necessary. The desirability of avoiding aerated waters has been already alluded to. When constipation is troublesome the addition of beef-tea, if it is not already being used, will often have the required laxative effect. If the patient is already supplied with it the quantity given may be considerably increased, or it may be made stronger. A little fluid magnesia may also be added to the milk. If haemorrhage should occur an absolute starvation is indicated for the first twenty-four or thirty-six hours, the object being to entirely rest the intestine and to avoid encouraging peristalsis. Neither milk nor water should be allowed even in the smallest quantities. The apparent cruelty of this proceeding is much diminished by the fact that in such cases morphia or opium is usually given freely, also with the object of checking peristalsis. The patient, then, is too much under the influence of the opiate to notice the withdrawal of his food and water. After twenty-four or thirty-six hours, according to the strength of the patient and the occurrence, or not, of further haemorrhage, I usually order a half teaspoonful of bovinine in two or three drachms of iced water as the first food, and this may be repeated every two or four hours. Twelve or twenty-four hours later peptonized milk may be added, given in teaspoonful doses at first, and given every hour if the patient is awake. The amount of milk may be rapidly increased if the bleeding does not recur, the patient usually receiving one ounce every two hours within seventy-two hours of his haemorrhage, in addition to meat juice or chicken jelly. If this is well borne, double that amount may be given on the following day. It is almost unnecessary to add that if the patient has been previously on some alcoholic stimulant this must be withheld, unless the haemorrhage has been so profuse as to render him practically pulseless, in which case it will be necessary to administer brandy very cautiously in half teaspoonful doses at frequent intervals, taking the greatest care not to improve the pulse too much or too suddenly.

If perforation has occurred it is obvious that recovery can hardly be considered as possible unless an operation is performed, so the question of diet is of little practical importance. It is advisable, however, to cease feeding by the mouth for the few hours which elapse before the perforation is surgically dealt with. On the other hand free stimulation may be necessary, and brandy must be given by the mouth or rectum as circumstances dictate. After the operation the nourishment should be very cautiously administered, as it is exceedingly important to prevent the occurrence of vomiting. Small quantities, say half an ounce, of iced peptonized milk, may be given hourly, and raw meat juice or chicken jelly will be found useful. Rectal feeding may be preferred and in any case small saline injections of from 6-10 oz. are often of great service. If the case is regarded as inoperable very similar treatment to that of haemorrhage is necessary, as it is only by checking peristalsis and keeping the intestine empty that that exceedingly rare result, the natural cure of a perforation, may be brought about.

Of other conditions likely to complicate the course of an enteric fever persistent vomiting may require a modification of the diet. In this case peptonizing the milk may be first tried. If that fails iced albumin water may be given. Raw meat juice is sometimes taken well when milk is not tolerated by the stomach. As a last resort rectal feeding may be necessary. In convalescence such conditions as phlebitis, periostitis, or skin abscesses call rather for an increase than a diminution of the diet, always provided the pyrexia is not so decided as to interfere much with the gastric digestion.

General Considerations

The above lines of dieting have answered very well in my experience, and they are recommended especially to those who, having only a limited experience of enteric fever, are anxious to adopt a perfectly safe method. Like all other systems, this one demands considerable supervision on the part of the medical man, and much care and attention on the part of the nurse. It is well to remember that the more strictly a patient is dieted the more he is liable to suffer from any sudden irregularity in his diet. The physician should inspect the stools frequently, to see whether the milk has been well digested and any appearance of curds, after the first few days of treatment, should arouse the suspicion that the milk may have been given improperly. The abdomen, also, should be inspected and palpated daily. Any increase of tumidity or tenseness suggests either imperfect digestion or some want of care in the feeding. The first can be usually remedied by modifying the diet.

As has already been stated, other methods of dieting, chiefly on more liberal lines, have been strongly advocated, and the success which they have met with at the hands of competent physicians has been such as to demand our most earnest attention. It has been thought well, therefore, to mention some of the more important. Their study is instructive as, when dealing with patients who cannot tolerate milk, we are often perplexed to know what may be safely substituted for it.

Diet For Children

It is obvious that except in the youngest children the diet, as recommended for adults, can in most cases be given. Any modification of it should be in the direction of caution rather than liberality. Children as a rule tolerate milk and thrive on milk much better than adults, and a milk diet in the acute stage, gradually increased to soft solids in convalescence and solids a little later than is recommended for adults, will in most instances be found quite satisfactory. Stimulants are better avoided, especially in the case of younger children.

The diets suggested on p. 323 may of course be much modified. They are merely included to express graphically the progress of a case. The amounts of milk given must of course depend on the patient's inclination for food and his toleration of milk. Thus 4 oz. may be given in a prolonged case with much wasting provided it is well digested. If porridge is not liked, bread and milk may take its place, or the patient may prefer Benger's food, or a beaten-up egg in milk at the corresponding times of the day. The changes may be rung with these foods for patients whose appetites are capricious. A few methods for preparing such foods are appended.

Oat Flour Porridge, Or Gruel

Soak the oat flour in a little cold water for at least two hours. Then strain through a fine sieve. Bring some cold water to the boil and add a liberal allowance of salt, making the water more salt than a person in health would find agreeable. Stir in the strained oat flour and stir steadily till the mixture again boils. Then keep it at the boil for half an hour, stirring at intervals. A small teacupful of this porridge with milk added to fill a breakfast cup is a reasonable allowance for an adult patient to start with.

Suggested Diet For Adults

Acute Stage.

Prolonged Case or Relapse.

Early Convalescence (first few days of normal temperature).

Convalescence.

4 a.m.

Hot beef or chicken tea, 7 oz.; milk, 3 oz.

Beef-tea, 10 oz.

Beef-tea, 10 oz.

6 a.m.

Milk, 3 oz., diluted.

Milk with plasmon.

Oat flour porridge with milk.

Oat flour porridge, milk.

8 a.m.

Milk, 3 oz., diluted.

Milk, 3 oz., with half a switched egg.

Tea, thin bread and butter.

Tea, eggs, bread and butter.

10 a.m.

Milk, 3 oz., diluted.

Milk, 3 oz., diluted.

Milk, 6 oz. to 10 oz.

Milk (if hungry).

12 noon.

Hot beef or chicken tea,

7 oz.; milk, 3 oz.

Hot beef-tea, 10 oz.; wine jelly; milk, 3 oz.

Beef-tea thickened with rice, fish, milk pudding, jelly.

Soup, fish or chicken, milk pudding with stewed fruit, jelly with cream.

2 p.m.

Milk, 3 oz., diluted.

Milk, 3 oz.

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-

4 p.m.

Milk, 3 oz., diluted, and a cup of weak tea.

Milk, 3 oz.; tea.

Tea, thin bread and butter, jelly, such as apple jelly.

Tea, a boiled egg, bread, butter and jam.

6 p.m.

Milk, 3 oz., diluted.

Milk, 3 oz., with half a switched egg.

Milk, 6 oz. to 10 oz.

8 p.m.

Milk, 3 oz., diluted.

Milk with plasmon.

Oat flour porridge with milk.

Oat flour porridge with milk, bread and butter.

10 p.m.

Hot beef or chicken tea,

7 oz.; milk, 3 oz.

Hot beef or chicken tea,

10 oz.; milk, 3 oz.

Beef-tea (if awake, or later).

Hot beef-tea (if awake in the night).

12 night

Milk, 3 oz. (if awake, if not, at 2 a.m.).

Milk, (if awake, if not, at 2 a.m.).

Milk (if awake).

Plasmon

Put a dessertspoonful into a cup with a little lukewarm water and stir into a cream. To make a small teacupful put a little milk in a saucepan. Bring it to the boil. Stir in the plasmon. Boil again. Have the white of an egg ready switched. Stir it in and add sugar to taste.

Bread And Milk

Grate bread crumbs very finely. Bring milk to the boil. Stir in the crumbs slowly, letting them fall constantly from the hand. Let it boil twenty minutes. Add if desired some switched egg or the switched white of an egg. Add sugar to taste.