We are indebted chiefly to Dr. Karell, of St. Petersburg, for our knowledge of the value of milk as an exclusive diet, and to Dr. Donkin for the extension of Karell's treatment to diabetes. I shall formulate as curtly as possible the rules to be followed in using milk as an exclusive diet in dyspeptic states, and in anaemia with obesity, and in the latter state uncomplicated by defective haemic conditions.

For fuller statements as to the reasons for the various rules to be observed in using milk, I must refer the reader to Karell's paper and to Donkin's book.

Have the utmost care used as to preservation of the milk employed, and as to the perfect cleansing of all vessels in which it is kept. Use well-skimmed milk, as fresh as can be had, and, if possible, let it be obtained from the cow twice a day. Or if this is not possible, or where any doubt exists as to the condition of the milk, or any difficulty is experienced in keeping it fresh, it may be pasteurized as soon as received by heating it to 160, keeping it some minutes at this point, and at once chilling on ice. For this purpose it is best to have the milk in bottles, and to heat by immersing the bottles in a water-bath.

For longer preservation, as, for example, when travelling, sterilizing may be more thoroughly done by greater heat and lengthened immersion.

Still, these should be expedients for use only when milk cannot be secured fresh and in good order, as it is more than doubtful if the milk is so well borne when it has been altered by these processes.

For ordinary daily use it might be better to let all the milk for the day be peptonized in the morning with pancreatic extract, to the extent which is found to be agreeable to the patient's taste, and then preserve it by placing it upon ice. In this way milk may be kept for several days. Then, too, it has been found that where even skimmed milk upsets the stomach of patients, milk prepared in this manner can be taken without trouble. In peptonizing, the directions which accompany the powders to be used for that purpose should be followed carefully. It is to be remembered that if the patient desires to take the milk warm, the process of conversion into peptones, which has been stopped by the cold, will be promptly started again when the fluid is warmed, and then a very few minutes will suffice to make it disagreeably bitter. At first the skimming should be thorough, and for the treatment of dyspepsia or alb.u.minuria the milk must be as creamless as possible. The milk of the common cow is, for our purposes, preferable to that of the Alderney. It may be used warm or cold, but, except in rare cases of diarrhoea, should not be boiled.

It ought to be given at least every two hours at first, in quant.i.ties not to exceed four ounces, and as the amount taken is enlarged, the periods between may be lengthened, but not beyond three hours during the waking day, the last dose to be used at bedtime or near it. If the patient be wakeful, a gla.s.s should be left within reach at night, and always its use should be resumed as early as possible in the morning. A little lime-water may be added to the night milk, to preserve it sweet, and it should be kept covered.

The milk given during the day should be taken at set times, and very slowly sipped in mouthfuls; and this is an important rule in many cases.

Where it is so disagreeable as to cause great disgust or nausea, the addition of enough of tea or coffee or caramel or salt to merely flavor it may enable us to make its use bearable, and we may by degrees abandon these aids. Another plan, rarely needed, is to use milk with the general diet and lessen the latter until only milk is employed. If these rules be followed, it is rare to find milk causing trouble; but if its use give rise to acidity, the addition of alkalies or lime-water may help us, or these may be used and the milk scalded by adding a fourth of boiling water to the milk, which has been previously put in a warm gla.s.s. Some patients digest it best when it has the addition of a teaspoonful of barley-or rice-water to each ounce, the main object being to prevent the formation of large, firm clots in the stomach,--an end which may also be attained by the addition at the moment of drinking of a little carbonated water from a siphon. For the sake of variety, b.u.t.termilk may be subst.i.tuted for a portion of the fresh milk, and though less nourishing it has the advantage of being mildly laxative.

When used as an exclusive diet, skimmed milk gives rise to certain very interesting and what I might call normal symptoms. Since at first we can rarely give enough to sustain the functions, for several days the patient is apt to lose weight, which is another reason why exercise is in such cases undesirable. This loss soon ceases, and in the end there is usually a gain, while in most rest cases an exclusive milk diet may be dispensed with after a week. Where milk is taken alone for weeks or months, it is common enough to observe a large increase in bodily weight. I have seen several times active men, even laboring men, live for long periods on milk, with no loss of weight; but large quant.i.ties have to be used,--two and a half to three gallons daily. A gentleman, a diabetic, was under my observation for fifteen years, during the whole of which time he took no other food but milk and carried on a large and prosperous business. Milk may, therefore, be safely a.s.serted to be a sufficient food in itself, even for an adult, if only enough of it be taken.

During the first week or two, exclusive milk diet gives rise to a marked sense of sleepiness. It causes nearly always, and even for weeks of its use, a white and thick fur on the tongue, and often for a time an unpleasant sweetish taste in the early morning, neither of which need be regarded. Intense constipation and yellowish stools of a peculiar odor are usual. Of the former I shall speak in connection with the use of milk in special cases. The influence of milk on the urinary secretion is more remarkable, and has not been as yet fully studied.

There is, of course, a large flow of urine; and in dropsical cases due to renal maladies this may exceed the ingested fluid and carry away very rapidly the dropsical acc.u.mulations. It is sometimes annoying to nervous persons because of the frequent micturition it makes necessary. I have discovered that while skimmed milk alone is being taken, uric acid usually disappears almost entirely from the urine, so that it is difficult to discover even a trace of this substance; nor does it seem to return so long as nothing but creamless milk is used. Almost any large addition of other food, but especially of meat, enables us to find it again. Creatine and creatinine also seem to lessen in amount, but of the extent of this change I am not as yet fully informed.

A yet more singular alteration occurs as to the pigments. If after a fortnight or less of exclusive milk diet we fill with the urine a long test-tube, and, placing it beside a similar tube of the ordinary urine of an adult, look down into the two tubes, we shall observe that the milk urine has a singular greenish tint, which once seen cannot again be mistaken. If we put some of this urine in a test-tube carefully upon hot nitric acid, there is noticed none of the usual brown hue of oxidized pigment at the plane of contact. In fact, it is often difficult to see where the two fluids meet.

The precise nature of this greenish-yellow pigment has not, I believe, been made out; but it seems clear that during a diet of milk the ordinary pigments of the urine disappear or are singularly modified. A single meal of meat will at once cause their return for a time.

These results have been carefully re-examined at my request by Dr.

Marshall in the Laboratory of the University of Pennsylvania, and his results and my own have been found to accord; while he has also discovered that during the use of milk the substances which give rise to the ordinary faecal odors disappear, and are replaced by others the nature of which is not as yet fully comprehended. The changes I have here pointed out are remarkable indications of the vast alterations in a.s.similation and in the destruction of tissues which seem to take place under the influence of this peculiar diet. Some of them may account for its undoubted value in lithaemic or gouty states; but, at all events, they point to the need for a more exhaustive study both of this and of other methods of exclusive diet.

As regards milk, enough has here been said to act as a guide in its practical use in the cla.s.s of cases with which we are now concerned; but I may add that it is sometimes useful, as the case progresses, to employ in place of milk, or with it, some one of the various "children's foods," such as Nestle's food, or malted milk.

Before dealing with the treatment of the anaemic and feeble and more or less wasted invalids who require treatment by rest and its concomitant aids, I desire to say a few words as to the use of rest, milk dietetics, and ma.s.sage in people who are merely c.u.mbrously loaded with adipose tissues, and also in the very small cla.s.s of anaemic women who are excessively fat and may or may not be hysterical, but are apt to be feeble and otherwise wretched.

Karell has pointed out that on creamless milk diet fat people lose flesh; and this is true; so that sometimes this mode of lessening weight succeeds very well. But it does not always answer, because, as in Banting, loss of weight is apt to be accompanied with loss of strength, so that in some cases the results are disastrous, or at least alarming.

I do not know that this is ever the case if the directions of Mr.

Harvey[26] are followed with care and the weight very deliberately lessened. But for this few people have the patience; and, even if they can be induced to follow out a strict diet, it is often useful to be able to cut off very rapidly a large amount of weight, and so shorten the period of strict regimen, or at least put over-fat persons in a condition to exercise with a freedom which had become difficult, and thus to provide them with a healthful means of preventing an acc.u.mulation of adipose matter. This can be done rapidly and with safety by the following means. The person whose weight we decide to lessen is placed on skimmed milk alone, with the usual precautions; or at once we give skimmed milk with the usual food, and in a week put aside all other diet save milk and all other fluids. When we find what quant.i.ty of milk will sustain the weight, we diminish the amount by degrees until the patient is losing a half-pound of weight each day, or less or more, as seems to be well borne. Meanwhile, during the first week or two rest in bed is enjoined, and later for a varying period rest in bed or on a lounge is insisted upon, while at the same time ma.s.sage is used once or twice a day, and later in the case Swedish movements. At the same time, the pulse and weight are observed with care, so that if there be too rapid loss, or any sign of feebleness, the diet may be increased. In many such cases I allow daily a moderate amount of beef- or chicken- or oyster-soup,--more as a relief to the unpleasantness of a milk diet than for any other reason.

When the weight has been sufficiently lowered, we add to the diet beef, mutton, oysters, etc., and finally arrange a full diet list to include but a moderate amount of hydro-carbons. Meanwhile, the milk remains as a large part of the food, and the active Swedish movements are still kept up as a habit, the patient being directed by degrees to add the usual forms of exercise.

If we attempt to make so speedy a change in weight while the patient is afoot, the loss is apt to be gravely felt; but with the precautions here advised it is interesting and pleasant to see how great a reduction may be made in a reasonable time without annoyance and with no obvious result except a gain in health and comfort.

Cases of anaemia in women with excess of flesh have to be managed in a somewhat similar fashion, but with the utmost care. In such persons we have a loss of red blood-globules, perhaps lessened haemoglobin, weak heart, rapid pulse, and general feebleness, with too much fat, but not, or at least rarely, extreme obesity. The milder cases may profit by iron, with rest and very vigorous ma.s.sage, but in old cases of this kind--they are, happily, rare--the best plan is to put the patient at rest, to use ma.s.sage, restrict the diet to skimmed milk, or to milk and broths free from fat, and with them, when the weight has been sufficiently lowered, to give iron freely, and by degrees a good general diet, under which the globules rise in number, so that even with a new gain in flesh there comes an equal gain in strength and comfort. The ma.s.sage must be very thoroughly done to be of service, and it is often difficult to get operators to perform it properly, as the manipulation of very fat people is excessively hard work. As to other details, the management should be much the same as that which I shall presently describe in connection with cases of another kind.

I add two cases in ill.u.s.tration of the use of rest, milk, and ma.s.sage in the treatment of persons who are both anaemic and overloaded with fat.

Mrs. P., aet. 45, weight one hundred and ninety pounds, height five feet four and a half inches, had for some years been feeble, unable to walk without panting, or to move rapidly even a few steps. Although always stout, her great increase of flesh had followed an attack of typhoid fever four years before. Her appearance was strikingly suggestive of anaemia.

She was subject to constant attacks of acid dyspepsia, was said to be unable to bear iron in any form, and had not menstruated for seven months. She had no uterine disease, and was not pregnant. Two years before I saw her she had been made very ill owing to an attempt to reduce her flesh by too rapid Banting, and since then, although not a gross or large eater, she had steadily gained in weight, and as steadily in discomfort.

She was kept in bed for five weeks. Ma.s.sage was used at first once daily, and after a fortnight twice a day, while milk was given, and in a week made the exclusive diet. Her average of loss for thirty days was a pound a day, and the diet was varied by the addition of broths after the third week, so as to keep the reduction within safe limits. Her pulse at first was 90 to 100 in the morning, and at night 80 to 95, her temperature being always a half degree to a degree below the normal. At the third week the latter was as is usual in health, and the pulse had fallen to 80 in the morning, and 80 to 90 at night.

After two weeks I gave her the lactate of iron every three hours in full doses. In the fourth week additions were made to her diet-list, and Swedish movements were added to the ma.s.sage, which was applied but once a day; and during the fifth week she began to sit up and move about. At the seventh week her pulse was 70 to 80, her temperature natural, and her blood-globules much increased in number. Her weight had now fallen to one hundred and forty-five pounds, and her appearance had decidedly improved. She left me after three and a half months, able to walk with comfort three miles. She has lived, of course, with care ever since, but writes me now, after two years, that she is a well and vigorous woman.

Her periodical flow came back five months after her treatment began, and she has since had a child.

Early in the spring of 1876, Mrs. C., aet. 40, came under my care with partial hysterical paralysis of the right and hemi-anaesthesia of the left side. She had no power to feel pain or to distinguish heat from cold in the left leg and arm, though the sense of touch was perfect. The long strain of great mental suffering had left her in this state and rendered her somewhat emotional. Her appet.i.te was fair, but she was strangely white, and weighed one hundred and sixty-three pounds, with a height of five feet five inches. As she had had endless treatment by iron, change of air, and the like, I did not care to repeat what had already failed. She was therefore put at rest, and treated with milk, slowly lessened in amount. Her stomach-troubles, which had been very annoying, disappeared, and when the milk fell to three pints she began to lose flesh. With a quart of milk a day she lost half a pound daily, and in two weeks her weight fell to one hundred and forty pounds. She was then placed on the full treatment which I shall hereafter describe.

The weight returned slowly, and with it she became quite ruddy, while her flesh lost altogether its flabby character. I never saw a more striking result.

I have been careful to speak at length of these fat anaemic cases, because, while rare, they have been, to me at least, among the most difficult to manage of all the curable anaemias, and because with the plan described I have been almost as successful as I could desire.

Let us now suppose that we have to deal with a person of another and different type,--one of the larger cla.s.s of feeble, thin-blooded, neurasthenic or hysterical women. Let us presume that every ordinary and easily attainable means of relief has been utterly exhausted, for not otherwise do I consider it reasonable to use so extreme a treatment as the one we are now to consider. Inevitably, if it be a woman long ill and long treated, we shall have to settle the question of uterine therapeutics. A careful examination is made, and we learn that there is decided displacement. In this case it is well to correct it at once and to let the uterine treatment go on with the general treatment. If there be bad lacerations of the womb or perineum, their surgical relief may await a change in the general status of health,--say at the fourth or fifth week. If there be only congestive or other morbid states of the womb or ovaries, they are best left to be aided by the general gain in health; but in this as in every other stage of this treatment it is unwise, and undesirable therefore, to lay down too absolute laws. Having satisfied ourselves as to these points, and that rest, etc., is needful, we begin treatment, if possible, at the close of a menstrual period, because usually the monthly flow is a time at which there is little or no gain, and by starting our treatment when it is just over we save a week of time in bed.

The next step is, usually, to get her by degrees on a milk diet, which has two advantages. It enables us to know precisely the amount of food taken, and to regulate it easily; and it nearly always dismisses, as by magic, all the dyspeptic conditions. If the case be an old one, I rarely omit the milk; but, although I begin with three or four ounces every two hours, I increase it in a few days up to two quarts, given in divided doses every three hours. If a cup of coffee given without sugar on awaking does not regulate the bowels, I add a small amount of watery extract of aloes at bedtime; or if the constipation be obstinate, I give thrice a day one-quarter of a grain of watery extract of aloes with two grains of dried ox-gall. I find the simple milk diet a great aid towards getting rid of chloral, bromides, and morphia, all of which I usually am able to lay aside during the first week of treatment.[27] Nor is it less easy with the same means to enable the patient to give up stimulus; and I may add that in the treatment of the congested stomach of the habitual hard drinker the milk treatment is of admirable efficacy. As I have spoken over and over of the use of stimulus by nervous women, I should be careful to explain that anything like great excess on the part of women of the upper cla.s.ses, in this country at least, is, in my opinion, extremely rare, and that when I speak of the habit of stimulation I mean only that nervous women are apt to be taught to take wine or whiskey daily, to an extent that does not affect visibly their appearance or demeanor.

Meanwhile, the mechanical treatment is steadily pursued, and within four days to a week, when the stomach has become comfortable, I order the patient to take also a light breakfast. A day or two later she is given a mutton-chop as a mid-day dinner, and again in a day or two she has added bread-and-b.u.t.ter thrice a day; within ten days I am commonly able to allow three full meals daily, as well as three or four pints of milk, which are given at or after meals, in place of water.

After ten days I order also two to four ounces of fluid malt extract before each meal. The fluid malt extracts which now reach us from Germany have become less trustworthy than they formerly were. Some of them keep badly, and are uncertain in composition, one bottle being good, another bad. The more constant, and at the same time most agreeable, extracts are those now made in this country. Although their diastasic powers are usually less than is claimed for them, and vary greatly even in the best makes, they so far have seemed to me on the whole more satisfactory than the imported malts. It is very desirable that a thorough chemical study should be made of the various malt extracts, solid and liquid. I am sure that some of them are defective in composition, or vary notably as to the amount of alcohol they contain.

No troublesome symptoms usually result from this full feeding, and the patient may be made to eat more largely by being fed by her attendant.

People who will eat very little if they feed themselves, often take a large amount when fed by another; and, as I have said before, nothing is more tiresome than for a patient flat on her back to cut up her food and to use the fork or spoon. By the plan of feeding we thus gain doubly.

As to the meals, I leave them to the patient's caprice, unless this is too unreasonable; but I like to give b.u.t.ter largely, and have little trouble in getting this most wholesome of fats taken in large amounts. A cup of cocoa or of coffee with milk on waking in the morning is a good preparation for the fatigue of the toilet.

At the close of the first week I like to add one pound of beef, in the form of raw soup. This is made by chopping up one pound of raw beef and placing it in a bottle with one pint of water and five drops of strong hydrochloric acid. This mixture stands on ice all night, and in the morning the bottle is set in a pan of water at 110 F. and kept two hours at about this temperature. It is then thrown on to a stout cloth and strained until the ma.s.s which remains is nearly dry. The filtrate is given in three portions daily. If the raw taste prove very objectionable, the beef to be used is quickly roasted on one side, and then the process is completed in the manner above described. The soup thus made is for the most part raw, but has also the flavor of cooked meat.[28]

In difficult cases, especially those treated in cool weather, I sometimes add, at the third week, one half-ounce of cod-liver oil, given half an hour after each meal. If it lessen the appet.i.te, or cause nausea, I employ it thrice a day as a rectal injection; and in cases where the large doses of iron used cause intense constipation, I find the use of cod-oil enemata doubly valuable, by acting as a nutriment and by disposing the bowels to act daily. This may be given as an emulsion with pancreatic extract. This will suit some people well, and result in a single pa.s.sage daily, but in others may be annoying, and be either badly retained or not retained at all, and may give rise to tenesmus.

The question of stimulus is a grave one. In too many cases which come to me, I have to give so much care to break off the use of all forms of alcoholic drinks that I am loath to resort to them in any case, although I am satisfied that a small amount is a help towards speedy increase of fat. Its use is, therefore, a matter for careful judgment, and in persons who have never taken it in excess, or as a habit, I prefer to give, with the other treatment, a small daily ration of stimulus: an ounce a day of whiskey in milk, or a gla.s.s of dry champagne or red wine, seems to me useful as an adjuvant, and as increasing the capacity to take food at meals. Nevertheless, alcohol is not essential, and for the most part I give none, except the small amount--some four per cent.--present in fluid malt extracts. Even this is found to excite certain persons, and it is in such cases easy to subst.i.tute the thicker extracts of malt, or the j.a.panese extract, made from barley and rice.

So soon as my patient begins to take other food than milk, and sometimes even before this, I like to give iron in large doses. In hospital practice the old subcarbonate answers very well, being cheap, and not unpalatable when shaken up in water or given in an effervescent draught of carbonated waters. In private practice large doses of salts of iron, as four to six grains of lactate at meal-time, are satisfactory; but the form of iron is of less moment than the amount.

Very often I meet with women who cannot take iron, either because it disturbs the stomach, causes headache, or constipates, or else because they have been told never to take iron. In the latter case I simply add five grains of the pyrophosphate to each ounce of malt, and give it thus for a month unknown to the patients. It is then easy to make clear to them that iron is not so difficult to take as they had been led to believe, and when it has ceased to disagree mentally I find that I am able to fall back on the coa.r.s.er method. If iron constipate, as it may and does often do when used in these large doses, the trouble is to be corrected by fruit, and especially pears, by the pill of the watery extract of aloes and ox-gall already mentioned, by extracts of cascara or of juglans cinerea, which may be added to the malt extract ordered with the meals, or by enemata of oil, or oil and glycerin, or a glycerin suppository. The instances in which iron gives headache and sense of fulness are very rare when the patient is undergoing the full treatment described, and, as a rule, I disregard all such complaints, and find that after a time I cease to hear anything more of these symptoms.

Unless some especial need arises, iron, in some form, is the only drug I care to use until the patient begins to sit up, when I order nearly always sulphate of strychnia, in rather full doses, thrice a day, with iron and a.r.s.enic.

Probably no physician will read the account I have here detailed of the vast amount of food which I am enabled to give, not only with impunity from dyspepsia, but with lasting advantage, without some sense of wonder; and, for my own part, I can only say that I have watched again and again with growing surprise some listless, feeble, white-blooded creature learning by degrees to consume these large rations, and gathering under their use flesh, color, and wholesomeness of mind and body. It is needless to say that it is not in all cases easy to carry out this treatment.

When the full treatment has been reached, and kept up for a few days, I begin to watch the urine with care, because if the patient be overfed the renal secretion speedily betrays this result in the precipitation of urates. When this occurs at all steadily, I usually give directions to lessen the amount of food until the urine is again free from sediment.

Nearly always at some time in the progress of the case there are attacks of dyspepsia, when it suffices to cut down the diet one-half, or to give milk alone for a day or two. Diarrhoea is more rare, and has to be met in like manner; or, if obstinate, it may be requisite to give the milk boiled. Occasionally the rapid increase of blood is shown by nasal hemorrhage, which needs no especial treatment.

Perhaps I shall make myself more clear if I now relate in full the diet-list of some of my cases, and the mode of arranging it.

I take the following case as an ill.u.s.tration from my note-book:

Mrs. C., a New England woman, aet. 33, undertook, at the age of sixteen, a severe course of mental labor, and within two years completed the whole range of studies which, at the school she went to, were usually spread over four years. An early marriage, three pregnancies, the last two of which broke in upon the years of nursing, began at last to show in loss of flesh and color. Meanwhile, she met with energy the multiplied claims of a life full of sympathy for every form of trouble, and, neglecting none of the duties of society or kinship, yet found time for study and accomplishments. By and by she began to feel tired, and at last gave way quite abruptly, ceased to menstruate five years before I saw her, grew pale and feeble, and dropped in weight in six months from one hundred and twenty-five pounds to ninety-five. Nature had at last its revenge. Everything wearied her,--to eat, to drive, to read, to sew.

Walking became impossible, and, tied to her couch, she grew dyspeptic and constipated. The asthenopia which is almost constantly seen in such cases added to her trials, because reading had to be abandoned, and so at last, despite unusual vigor of character, she gave way to utter despair, and became at times emotional and morbid in her views of life.

After numberless forms of treatment had been used in vain, she came to this city and pa.s.sed into my care.

At this time she could not walk more than a few steps without flushing and without a sense of painful tire. Her morning temperature was 97.5 F., and her white corpuscles were perhaps a third too numerous. After most careful examination, I could find no disease of any one organ, and I therefore advised a resort to the treatment by rest, with full confidence in the result.

In this single case I give the schedule of diet in full as a fair example: