Dietetics.—The next consideration is that of food. As already laid down in the treatment of dyspepsia and other allied conditions, the fallacy of writing out a routine cut-and-dried diet table has been insisted upon. In the treatment of phthisis this fashionable error is especially to be avoided. Whilst it will be always necessary to carefully supervise the diet, the individual tastes of the patient should be most scrupulously considered, and, unless predilection be shown for worthless or unsuitable articles of diet which take the place of nutritious food, he should be permitted within generous limits to feed according to his fancy provided lie takes sufficient nutriment to fully meet the demands of his organism.
Food as a rule is of far more importance than drugs, and practically there need be no limit set to its amount. As much as the patient can be tempted to swallow may be administered. A well-mixed or varied diet is the hest for a consumptive patient in the early stages. It should be carefully cooked, and served in the most tempting fashion, and a good cook is often of more importance than a therapeutist. Fats should, when possible, form an important item in the daily food, and abundance of milk, eggs, and butter is generally within the reach of al], and they do not demand in their preparation much scientific knowledge of cookery. When the temperature is elevated and the digestive organs weakened, the patient may have to rely entirely upon a milk diet, and experience has proved that this of itself is a most valuable dietary in all stages of phthisis. Some patients can take cream. To live upon milk, 4 pints at least in the 24 hours will he required to meet the demands made upon the system; hut, as the great aim in dealing with phthisical patients is to administer more than is required to meet the waste, and to so improve the nutrition as to considerably add to the body weight, a larger quantity will he necessary, and in some of the sanatoria more than double this amount is given.
From what has been stated under the head of prevention the necessity' of seeing that the milk is free from tubercle bacilli cannot be exaggerated. It is not enough to see that the udder of the animal supplying the milk is free from disease; the tuberculin test should be employed. If we regard the human and bovine bacillus as antagonists, theoretically the milk of a tuberculous cow might within certain narrow limits be advantageous to a phthisical patient who is suffering from the human bacillus, but here the vital question of dosage is the important factor. It is a sad reflection to think that the milk of a tuberculous cow has been supplied to the extent of several pints per day to a patient in the early curable stage of phthisis when this milk itself has been deeply contaminated by the specific bacillus, which consequently was given in such large doses as to render the escape from a general tuberculosis impossible, yet the writer has known this to occur in at least three instances. If carefully sterilised, the patient should
be unable to detect any difference in the milk.
Buttermilk made in the process in which the entire milk of the cow is churned for the production of butter (not buttermilk made when only the cream of milk is churned) makes an invaluable article of diet. When taken 48 hours after churning, it is fairly acid, and is often appreciated and swallowed in large quantities by patients who cannot tolerate fresh milk.
Milk warm from the cow is believed to be more digestible than the cold liquid. A little good rum added is a great improvement. Jaccoud advised phthisical patients to repair twice a day to the cowhouse to drink the milk warm from the milking pails, and to inhale the moist sedative atmosphere of the place for some time, so as to have laryngeal and bronchial irritation soothed. Most patients could not tolerate such a tepid draught.
The milk of the mare, ass, goat, and sheep may be used, and the first two kinds of milk are easily digested. The Koumiss made from the fermented milk of the mare is a highly prized Russian remedy for phthisis.
As described in another part of the present volume a palatable and highly nutritious beverage may be prepared by mixing i part of slightly acid buttermilk and r part of water with 8 parts of cow's milk, putting the mixture into a loosely corked gallon jar, leaving it in a warm, but not hot, place, where it may be frequently and briskly shaken, and in 36 to 48 hours it is ready for use as a pleasant, sharp-tasted, thick liquid, which slightly effervesces. Some little skill and experience are required in producing a uniform result, and the patient should not give it up if the first and second results are unsatisfactory. After the first batch of this artificial koumiss has been successfully prepared the use of buttermilk may be entirely dispensed with, as an equal bulk of the koumiss liquid can be used instead in the preparation of each subsequent quantity. Where a phthisical subject takes to this home-brewed koumiss, as a rule all difficulty in feeding is overcome; but the article commonly known as buttermilk in England will not make koumiss. Whatever advantages are procurable from the presence in the stomach and intestines of the lactic acid-producing organisms are obtained by the use of this home-made liquid in a much higher state of activity than is possible by the use of the in numerable preparations placed on the market, many of which are useless.