Should the milk be peptonised ? The writer does not hesitate to say that this should not he resorted to as a routine practice in every case. With patients possessing good digestive powers it is generally unnecessary, and sometimes turns them against the loud. An inspection of the motions may settle the question. II much tirm curd, or if in liquid motions the undigested Ilaky coagula arc clearly visible, the diet must be altered. Either the patient is not being fed at proper intervals, or he is having more than it is possible for him to digest, or else his digestive powers are weakened, or else the irritability of the bowel is hurrying its contents too rapidly along the canal to permit of digestion and absorption, and a little reflection will dictate the best course in such cases.
Lime water or kali water may effect the desired change by its action upon the milk, and occasionally barley water is agreeable. Sometimes a change to beef tea or cold chicken jelly may set matters right, or a little good arrowroot may be boiled with the milk, or a very pure isinglass may be added. If the patient's vital powers arc low, the milk may then be peptonised by adding a little of the Liquor Pancreaticus.
In such a case the question of stimulants will have to come to the front, as will be presently discussed, and if these are indicated the re quisite dose of brandy or whiskey may he mixed with the milk before administration. This latter plan often succeeds better than any other, even in those cases where solid curd is vomited.
Where milk cannot be taken in sufficient amount. the question of liquid animal food must be considered. Some physicians give beef tea and soups in all cases as a matter of routine. These certainly may he given in typhus always, but in many eases of typhoid fever they excite or increase diarrhoea. and may do harm. In many cases. and. indeed, in nearly all cases at some period of their progress in typhoid fever, beef tea. strengthened by meat extracts, and good soups, carefully strained, are advantageous.
The clear strained soup made by boiling down half an average sized chicken or the equivalent of one pound of butcher's meat made into beef tea may be given during the twenty-four hours alternately with the doses of milk in most cases from the very beginning, if care be taken to suspend its administration upon the onset of diarrhoea. Constipation is often pre sent throughout the attack, and it is then that the value of animal soups is most apparent. Where the opposite condition is present. pure Gelatin
made into a firm jelly and flavoured with a little Sherry becomes a valuable article of food.
The writer's routine custom in hospital and private practice is to adhere to milk till constipation declares itself, and then either to suspend the milk entirely for a time, or to give an equal amount of beef tea or strained chicken soup alternately with it. At a later stage an occasional dose of mutton broth, carefully strained through a fine sieve and deprived of all fatty matters, will prove a substitute for Castor Oil or the enema. Raw beef juice and barley and oatmeal gruels well strained are praised by Ziemssen. Calyes'-foot jelly and gelatin blancmange are admissible, but only in cases where the patient is able to take a sufficient amount of milk or other valuable nourishment. Rennet, with a little carefully prepared currant jelly or strained fruit juice, may be permitted.
On any change from the pure milk diet the temperature chart is to be closely scanned, and it will be often observed that the rise which some times follows can he attributed to the animal food.
Much attention has in recent years been directed to what is known as the High-Calory dietetic treatment of typhoid fever, and results appear to be convincing in the report of Coleman, who treated 444 consecutive cases, half of which where placed on exclusive milk, and the other half on high-calory diet, with the result that the mortality in the first mentioned was 17'6, and in the latter only S•i. Carbohydrates in fair amount in conjunction with milk constitute the main element in this diet. The writer enters a protest against eggs, though their use was advocated by 11urchison„ Cavlev and others.
The so-called " empty //owe/ " treatment advocated by Ewart consists in feeding the patient on peptonised with the view of leaving the minimum of bowel residue.
When the fever has subsided for a few days, the physician will be tempted to permit a change in the diet. In contemplating this it will be advisable to summon up the mental picture of the possible state of the ulcerated Peyer's patches and solitary glands, and it will be advisable to refuse the patient's request for solids for ro days after the normal temperature has been reached.