In these cases the most appropriate form of treatment consists in a modified rest cure of, at the longest, three months' duration. The first three weeks of this time should be spent almost entirely in bed, the patient only rising to deuecate, urinate, and perform his necessary ablations, and after the first week to indulge in a few Swedish movements. In addition, twice a week a very hot bath should be administered. During the fourth week one hour per day should be spent in gentle outdoor exercise, and this should be increased to two and three hours in the fifth and sixth weeks respectively. The next six weeks should be spent in a country or seaside holiday, during which the patient should gratify his desire for exercise well within the limits of fatigue, and should particularly reserve one hour or more after each meal in which he should resume the recumbent posture, if possible in the open air.

The only treatment prescribed during all this period is the forced feeding, which I shall proceed to detail, and the application of an india-rubber bottle half full of very hot water right over the region of the stomach every two hours. It is important that this should not be too large - 12 inches by 8 inches is a useful size. It should only be half full of very hot water, should be covered with flannel, and it should rest to a greater extent on the lower ribs than on the yielding tissues over the gastric region. The object of this is, of course, to prevent restriction of the gastric movements by direct pressure, and on the other hand to stimulate the contraction of the gastric musculature by the application of heat all over its immediate neighbourhood. Towards the end of the treatment the cutaneous area of the epigastric region assumes the appearance of bacon rind - if, indeed, the cuticle does not peel off like the skin of a new potato.

The diet consists of two small meals, two large meals, and at least three glasses of hot milk at convenient intervals between meals. At 7.30 a.m. breakfast should be served in the shape of the yolks of two eggs poached on toast, bread and butter with marmalade or jam, and one or two tumbler-fuls of hot milk. At 10.15 a.m. one glass of hot milk. At 1 p.m. dinner, a typical example of which would be a little soup, three-quarters of a pound of any kind of flesh food (roasted), with potatoes and green vegetables, pudding, stewed fruit and cream, and 5 ounces of mineral water. At 4.14 p.m. bread, butter, jam, and one pint of hot milk. At 7 p.m. a supper like the dinner, and at 10 p.m. one glass of hot milk.

At first the unfortunate patient, who has not eaten a "square" meal for many years, perhaps, feels quite uncomfortable from the hyperalimentation, especially when sitting up in bed to eat; but the moment he lies down and obtains the soothing hot-water bottle his discomfort is exchanged for the glorious sensation of satiety and heavenly rest. The hot-water bottle should be applied both night and day, and for many months after the treatment proper is completed should be continued after meals and at bedtime. I am in complete accord with Dr. Hutchison when he says that the whole life of a gastroptotic patient must partake of the character of a more or less modified "rest-cure."

On such a modified system I have frequently known a patient put on 1 pound per day of much-needed weight, and although he lost a good deal of the excess of fat on resuming work, he retained a sufficient quantity to prevent the expenditure of his energy from exceeding the income. Nor is it necessary to initiate the treatment by a preliminary fast for two or three days, then passing on to a graduated system of dieting, as some do. Cases of the type I have mentioned do well on the full diet from the very first meal. No particular form of food is indicated. All that is necessary is to ensure a sufficient supply of good wholesome nutritive material, and I have obtained as good results on a fleshless system of diet as on a mixed diet, although the latter is always to be preferred.

Although my experience in this method is confined to functional cases of stomach ailments, I am quite certain that it would be suitable for many other forms of malnutrition, such as muco-membranous colitis, and neurotic cases of many kinds.

Its Rationale

The beneficent effects of this treatment are due in the first instance to the excessive quantities of food. Most cases consume with ease about 7 pounds of food per day, if we include the milk, and this is just a little less than double the total quantity of the day's rations of an average healthy man. The heat and energy value will not exceed 4,000 calories, which is again just twice what is required by a patient at absolute rest. The fact that practically no benefit is obtained unless the weight is materially increased confirms the view that hyperalimentation is the most important factor therein. The weight, however, must not only be increased: the increase must be maintained, and as we know that deposited fat is constantly being utilised by the tissues, this means that there is a daily renewal, for which purpose digestion and metabolism must be preserved at a higher standard than existed before the cure was undertaken. The internal work of the body is therefore much augmented, but the organs are able to work under better conditions, because, as there is no external work, and therefore less waste matter and fewer toxins to interfere with their functioning, all their energies are devoted to improving their own nutrition. The absence of all signs of indigestion and the regular daily action of the bowels - which is always a surprise to those who believe that the recumbent posture encourages constipation - most unquestionably demonstrate the improved condition of the stomach and bowels, whilst the cessation of the wearing, aching pains in the limbs proclaims in no uncertain manner that the toxins of fatigue have been effectively excreted. These indubitable benefits have been accomplished despite the enormous excess of nutriment in the tissues, disproving the statement that it is a factor in the production of disease. The large supplies of fluid in the shape of milk increase the urinary and cutaneous excretions, and doubtless have their share in the advantages derived.