Of these methods the most generally applicable and effective is the first - the treatment by an exclusively milk diet. It ought always to be tried in the first instance. Its success depends, in great measure, on the strict observance of the minutest detail, a fact that must be thoroughly impressed on and apprehended by the patient and his responsible attendants.
The patient is sent to bed in an airy sunny room, in which the temperature is kept uniformly above 60° Fahr. He should be clothed in flannel, and during the day when reading should wear a long sleeved shoulder wrap. The abdomen should be covered with a large cotton-wool pad firmly kept in position by a flannel binder. He must not be allowed to get up, but must use the bed pan when necessary.
Should pyorrhoea alveolaris or other condition of oral sepsis be present, as is often the case in this disease, appropriate local treatment must be instituted.
The bowels, in the first instance, had better be cleared by a small dose of castor oil or of pulvis rhei composita, the patient abstaining from all food pending the action of the aperient. Written directions are then given as follows.
1. Fresh milk, slightly warmed, to be the only food and drink.
2. The milk to be taken at intervals of two or of three hours, in divided quantities up to the aggregate amount of 3 pints in the twenty-four hours.
3. The milk must never be drunk down hurriedly, but slowly sipped with a spoon or sucked through a straw or fine glass tube in imitation of the natural way of ingesting milk.
4. After each feed the mouth must be rinsed out with an alkaline or antiseptic wash, and the teeth lightly brushed.
5. Unless the patient is very weak sleep must not be disturbed for feeding purposes.
6. If at any time there is a feeling of nausea or a want of appetite, one or more feeds should be intermitted.
7. Throughout the treatment the patient's weight should be taken every three or four days and accurately recorded.
If after a thorough trial of this treatment for a week there is no marked improvement, the diet must be modified. If, on the contrary, as is usually the case, improvement is marked attempts to increase the amount of milk must not be made too soon, not, indeed, till the patient clamours for more food and the motions are solid. In this case increments to the extent of half a pint per diem may be conceded every two or three days. When in this way the patient is taking 6 pints of milk, he usually begins to gain weight and may now be allowed to get on to the sofa or sit up for a few hours at a time, carefully clothed and in a warm room. Later, when he is on 7 or 8 pints a day, he may get out of doors on fine days with the usual precautions against chill, but he must not be allowed to take anything approaching active exercise.
Not until six weeks after the stools are formed and the soreness of the mouth and the abdominal distension have disappeared may any attempt be made to add to the dietary. It is well to put this off as long as possible, preferably until some indication of bile has appeared in the stools. When it is deemed advisable to add to the dietary such additions must at first be made tentatively and in small quantities, a corresponding amount of milk being deducted and the effect on the tongue and stools carefully observed. Any tendency to relapse must be at once regarded as indicating that the added food is unsuitable or premature, in which event a gentle aperient should be given and the exclusively milk diet reverted to until the temporary disturbance has subsided.
Provided that things are going well the following may be carefully introduced : Fruit, especially strawberries or bananas mashed up with a portion of the milk; raw or underdone eggs; well-boiled arrowroot, rice-water or barley-water; rusk, crisp thin toast, or pulled bread; custard, malted artificial food, stewed apple, chicken broth in which rice has been boiled and strained out; pounded chicken, chicken cream or panada; boiled sole or turbot; boiled, mashed and afterwards baked potato; and so gradually after several months reverting to regular meals and ordinary diet, but for a long time interdicting everything but the simplest and most digestible of food, and avoiding alcohol and beef, and unnecessary fluid at meals.
As already directed, the patient's weight must be frequently and regularly ascertained with the view not merely of avoiding underfeeding, but of obviating, what is equally dangerous, overfeeding. There must be no attempt, as is so often done, at pushing the milk or extras. A small weekly gain in weight of a pound or two indicates that nutrition is being efficiently conducted. To give more food in such circumstances is not merely unnecessary but it is dangerous, risking as it does an interruption of the physiological rest which our measures are directed to secure as far and as long as possible. For the same reason, as it obviates the necessity for large quantities of heat producing food, clothing should be warm; and, because it obviates the necessity for muscle-forming food, exercise should be reduced to a minimum. It seems hardly necessary to insist on what seems so obvious, were it not that experience shows that it is in consequence of the ignoring of these rudimentary principles that the milk treatment so often fails, in some instances, to cure or, at all events, to ameliorate the disease.
It sometimes happens that the milk treatment in this form fails from the outset; symptoms instead of abating increase and the patient rapidly runs down hill; or it may happen that after a period of temporary improvement the milk seems no longer to suit him; or, again, that it agrees with him so long as only 3 or 4 pints are consumed, but so soon as attempts are made to increase the amount diarrhoea and sore mouth return. Notwithstanding this apparent initial failure, it is inadvisable altogether to abandon the milk treatment without further effort. Reducing the amount, peptonizing or boiling the milk, diluting it with water or barley-water, condensing it by evaporation in a shallow dish placed on boiling water, and stirring the milk to prevent the formation of scum - which should it form must be discarded, giving it in the form of skimmed milk, or koumiss, or whey, or buttermilk, or in some form of clotted milk may be tried. In one or other of those ways success is sometimes attained. Not infrequently the addition of a little fruit, especially of strawberries, succeeds when milk alone fails, and certainly should be tried when possible.
In certain cases, so long as the total amount of milk consumed in the twenty-four hours does not exceed 3 or 4 pints, it is digested and absorbed, but whenever this inadequate amount is exceeded relapse occurs. In a proportion of instances the failure appears to depend on inadequate absorption of the watery element in the milk. In such instances the requisite amount of nourishment may be supplied by evaporating say 6 pints of milk to 4 or 3. Recently the use of buttermilk, and of living lactic acid ferments, etc., introduced with each feed of milk, and in other ways have been strongly advocated in sprue and chronic dysentery. It is claimed that by acidifying the contents of the alimentary canal, these organisms suppress the bacteria of putrefaction and so, being themselves harmless, conduce to recovery. This method is well worth a trial when milk in its ordinary form has failed.
One or other of these modifications of the milk treatment should be tried before the method is definitely abandoned. Should they fail one after the other, recourse must be had to some other method of feeding, the same careful observance of rest and warmth still being insisted on.