The common deficiency in the fatty foods requires attention. Milk of course contains a fair proportion of fat, but it should be reinforced with cream as early as possible, and butter should be taken freely. Fat bacon and sardines are other food-stuffs which can often be made use of. Pears and apples, if thoroughly stewed without an excess of added sugar, are often well borne, and can be taken with cream.

In the more severe cases four to six weeks of a milk and carbo-hydrate diet may be required to allay the symptoms, but in the large majority of patients in whom dyspeptic symptoms obtain, a much shorter period is sufficient, if the patient is kept from the outset at absolute rest in bed; and the rapidity with which abdominal symptoms disappear under this regime is sometimes very striking. Even in cases where gastric symptoms are wholly absent, rest in bed is advisable for a week or two at any rate, particularly in those patients whose appetite is defective or capricious; and the initial improvement may be rapidly continued when a fair amount of outdoor air and exercise is subsequently allowed.

Few chlorotics require such a lengthy and careful restriction of their diet. In many but little restriction need be imposed, a plainly cooked diet of fresh foods with a suitable proportion of carbo-hydrates, fats and proteins being successfully utilized; but, on the other hand, few of these patients can be allowed to continue their old habits, as the quality or the quantity of their food-stuffs is generally found to be defective. And the diet must be supervised for several months after recovery, if relapses are to be avoided.

The dietetic treatment of chlorosis is of course subsidiary to the administration of iron. It is rarely judicious to administer iron in any form so long as a milk and carbo-hydrate dietary is required; and digestive disturbances should be in complete abeyance.

Constipation, when present, requires very special attention, and drugs may be needed to ensure the daily evacuation of the bowels. If gastric symptoms are absent dietetic measures may be sufficient, a bulky and more or less irritating food residue securing the desired result. Brown bread, porridge, marmalade, fresh or stewed fruits (especially apples, pears, prunes, figs), the green vegetables, bananas, etc., may be employed; but it should always be remembered that the last named is the not infrequent cause of a mild form of colitis. It is usually well borne if cooked.

Drugs are generally required so long as the patient is upon a milk or farinaceous diet. Large enemata, frequently repeated, defeat the end in view, and should only be given as occasional helps; but glycerine enemata are often successful. Of drugs, Carlsbad water, sulphate of soda, castor oil, liquid extract of senna pods or of cascara, and the B.P. Pil. aloes et ferri, are those most useful. The saline sulphates have been decried on theoretical grounds, but practical experience seems to contradict the theory.

In a very small proportion of cases the digestive symptoms seem related not so much to actual gastric disability as to a hypersensitiveness, the result of the anaemia; and a successful issue can only be attained by improvement of the condition of the blood. Such cases are, however, the exception. There is generally a notable disproportion between the severity of the symptoms and the complaints; the patients are, as a rule, palpably neurotic; and there is an entire absence of objective evidence of gastro-intestinal wrong-doing.

The majority of patients suffering from gastric symptoms, however, require careful attention, and are speedily relieved by such a course of treatment as is indicated above, and any measures adopted on the supposition that the symptoms are neurotic in their origin should be carried out tentatively and with care.

The main difficulty in the treatment of chlorosis is the decision as to how radical the treatment should be. Is it necessary to confine this patient to bed and to a fluid diet? Or may a limited amount of exercise and a solid dietary be adopted from the start?

It is as a rule far more satisfactory to err on the safe side in such cases, and if the symptoms disappear rapidly, an equally rapid transition through the various stages can easily be made. On the other hand, continuance of the symptoms and a retrogression in the treatment is always disappointing from the patient's point of view.

Whenever sedative drugs are required, the dietary should be restricted to milk, or at any rate, the finer farinacea. There is no objection, however, to such aids to digestion as alkalies, pepsin and bitters, and small doses of these are often of value in promoting appetite or digestion.

Diets. Milk Diet

4 a.m..... Milk, 10 oz. (hot or cold).

8 a.m..... Bread and milk, 15 oz.

11 a.m..... Egg flip, 10 oz.

1 p.m..... Milk pudding with milk, 15 oz.

(Cornflour, ground rice, semolina, sago, tapioca, arrowroot, custard).

3 p.m..... Benger's food, 10 oz.

5.30 p.m. . . . Milk pudding or bread and milk, 10 oz. 8 p.m..... Milk, 10 oz.

The quantity of milk may be increased to 4-6 pints in the twenty-four hours.

Light Diet

4 am.....Milk, 10 oz.

8 a.m.....Milk or weak tea with milk, 10 oz.

Bread and butter, 2 oz.

White fish, boiled, with white sauce, 4 oz.

Or an egg, lightly boiled or poached.

11 a.m.....Milk, or Benger's food, 10 oz.

1 p.m.....Chicken or white soup, 10 oz.

Chicken or white fish, 4 oz.

Bread, 1 oz.

Potatoes, 2 oz.

Vegetables, 1 oz. (cauliflower, cabbage, sprouts, etc.).

Milk pudding, 10 oz. 5.30 p.m. . . . Milk or weak tea with milk, 10 oz.

Bread and butter, 2 oz.

An egg, or white fish, 4 oz. 8 p.m..... Milk, 10 oz.

Cream, 10 oz. per diem.

Full Diet

4 a.m.....Milk, 10 oz.

8 a.m.....Milk or weak tea with milk, 10 oz.

Bread and butter, 4 oz.

White fish, 4 oz.

Or an egg.

11 a.m.....Milk or Benger's food, 10 oz.

1 p.m.....Soup, 10 oz.

Meat, boiled or roasted, 6 oz. (chop, steak, mince, mutton, chicken).

Bread, 2 oz.

Potatoes, 2 oz.

Milk pudding, 10 oz. 5.30 p.m. . . . Milk or weak tea with milk, 10 oz.

Bread and butter, 4 oz.

An egg, or white fish, 4 oz. 8 p.m.....Milk, 10 oz.

Cream, 10 oz. per diem.

These diets, which are in use in my wards, have proved satisfactory in the large majority of anaemic cases. In private practice they have usually to be modified, but the general idea is maintained. The meals are taken at comparatively short intervals, and the chief meal is in the middle of the day, and is followed by a relatively long interval.

Patients, when on full diet, should rest quietly for at least half an hour after the larger meals, and for the same period before them; and efficient mastication must be insisted upon. Every effort should be made to ensure a sufficient variety in the food-stuffs so as to encourage appetite.

When constipation is persistent, the chief alterations in the diet are the substitution of brown bread for white, an increase in the amount of the green vegetables, and the addition of porridge and such fruits as are in season, in particular apples, pears and bananas. The fruit jellies, marmalade, dried or stewed plums, prunes and figs may also be used.

The following "card" of "fresh foods" is often useful.

Bread, unsweetened biscuits, scones.

Butter, jellies, marmalade.

Milk puddings (cornflour, arrowroot, sago, tapioca, semolina, rice).

Thick soups (white, potato, barley, etc.).

White fish (sole, whiting, haddock, cod).

Fresh young birds (chicken, pheasant, partridge, grouse).

Beef, mutton, tripe, rabbit.

Potatoes, cabbage, Brussels sprouts, cauliflower, peas, beans, lettuce, tomatoes. Grapes, strawberries, melons, bananas (in moderation), oranges, apples, pears. Milk, cream, curds and whey. Eggs, custard. Tea, to be infused for three minutes, and mixed with nearly an equal quantity of milk. No dried, salted, tinned, or preserved foods of any kind are allowed,, which may be added to the milk, and bacon.

The food must be roasted, boiled, stewed, or broiled. Sauces must not be highly seasoned. Condiments are to be used sparingly.

Fish Souffle

Six oz. haddock or whiting; 2 oz. butter; the yolks of three eggs and the whites of four; 2 oz. flour; 8 oz. fish stock; pepper and salt.

Remove the skin and bones from the fish, and after pounding the flesh thoroughly, pass it through a fine sieve. Put the butter and flour into a saucepan and rub together over the fire; add the fish stock, and stir until it boils. Add in order, pepper, salt, the fish pulp, the egg yolks and lastly the egg whites, which have already been beaten up stiffly. The mixture is poured into a well buttered tin, and baked in a moderate oven for 45 minutes.

Chicken Cream

The breast of a young chicken; pepper; salt; a small teacupful of cream.

Pound the chicken thoroughly and pass it through a fine sieve. Place the pulp in a small basin, with the pepper and salt, and beat with a fork for ten minutes, adding the cream very gradually. Place the mixture in a well wetted mould, cover with paper, and poach for twenty minutes in boiling water.