The dietetic treatment of anaemia requires, in the first place, that the most nutritious food should be supplied; secondly, care must be taken to insure its complete digestion and absorption. In all cases of anaemia the impoverished and watery condition of the blood reacts unfavourably upon the character of the digestive secretions and diminishes their organic elements. The secretions are therefore unable to digest the food with the necessary vigour, and it is often desirable to re-enforce them by the use of artificially prepared ferments or to give predigested food, making use of pancreatin, in the preparation of animal food, and diastase or malt extracts for the predigestion of amylaceous food (see pp. 358, 359).

At the commencement of treatment rest and a small amount of food may be required, but with improvement of the digestive organs the quantity of food must be rapidly increased, and four or five meals a day may be given. At first, if milk is well borne by the enfeebled digestive system, and if it is not distasteful to the patient, it should be the principal food. It may be drunk between meals, and especially at night on going to bed. Some of these patients who cannot digest milk with facility are able to take a mixture of equal parts of cream and hot water with ten grains of bicarbonate of soda and a teaspoonful of brandy to the tumbler (Yeo). Eggs in all forms which are of fairly easy digestion are an excellent food for anaemic subjects, and rare meat should be given in considerable quantities two or three times a day. Sandwiches made with pounded meat or beefsteak almost raw, which is placed between thin slices of bread and butter, may be taken with meals, or as a light lunch in the middle of the morning and afternoon. Inserting a crisp lettuce leaf in each sandwich makes it still more palatable and wholesome. Patients of this class often object very strongly to eating meat, and prefer pastry and sweets, but with tact and persuasion they can usually be induced to take it in some form.

Meat broths and consommes may be thickened with scraped meat, or raw scraped beef may be added to chocolate or Burgundy, or may be eaten in any manner agreeable to the patient. In this way large quantities of meat in an easily digestible form may be taken without tiring of it, as fat anaemic women are very apt to do. Young chlorotic girls should receive at least five or six ounces of albumin per diem. See gives as much as fourteen ounces of raw meat daily in some cases of chlorosis, and finds it especially serviceable for those patients whose weak stomachs rebel against the use of the different preparations of iron.

Anaemic patients often feel worse during the first half of the day. They then complain most of headache, languor, and anorexia, but they should be encouraged to begin the day early with nourishing albuminous food to counteract this condition. Van Noorden's system at the Berlin Charite is excellent, and he describes it as follows:

" I recommend chlorotic girls to drink slowly half a litre of milk of the best quality while they are yet in bed in the morning. They must take time, and occupy at least a quarter of an hour in consuming this quantity. They ought to rise half an hour later, and they should be rubbed briefly with a dry rough woollen towel. This is to be followed by the breakfast, consisting of a small cup of tea, one or two slices of buttered toast, and plenty of meat. I consider it extremely desirable - the physiological reasons for this are easy to defend - that these patients should take in at breakfast, before the daily work commences, as much albumin as possible. Two and a half hours later some bread and butter and two eggs are to be eaten, followed immediately afterwards by drinking a quarter of a litre of milk. If considered advisable for special reasons, a small glass of sherry is now permissible".

If the large quantities of meat recommended are not perfectly digested and absorbed, it is well to prescribe some preparation of pepsin with dilute hydrochloric acid. A concentrated meat diet almost always produces constipation if this condition does not already exist as a result of the anaemic and atonic condition of the intestinal wall, or the giving of iron. It is well to counteract this tendency by the use of draughts of hot water and of purees of fresh vegetables, whole-meal bread, oatmeal, and such fruits as stewed prunes, apples, and the juice of oranges and grape fruit. (See Constipation).

The various Italian pastes, such as macaroni, vermicelli, and polenta, with meat gravies, are suggested by Yeo. But with those patients in whom there is a tendency to overproduction of fat, withholding of hydrocarbons from the diet is highly desirable.

For others who, besides being anaemic, are thin and poorly nourished, it is well to add some simple forms of starchy food and a good deal of fat with the meals. Van Noorden says:

"For a well-nourished, moderately fat, chlorotic girl, weighing sixty kilos, I would consider the following diet as eminently suitable :

" 120 grammes albumin =

492 calories.

60 " fat =

558 "

270 " carbohydrates =

1,110 "

Total...................

2,160 "

(i. e., 36 calories per kilo of body weight.)"

The eating of fats is to be encouraged to the limit of toleration. Cream and large quantities of butter are recommended when easily digested, and they can be made to replace cod-liver oil when the patient is unable to take this form of fat. Many patients can digest broiled fat bacon with ease. Two or three eggs beaten with boiling water or milk, with the addition of sugar and spices and a table-spoonful of brandy or sherry, make a useful form of eggnog, which can be given two or three times during the day between meals.

The use of glycerin extracts and of emulsions of bone marrow has been advocated for anaemia, but the results have not been markedly satisfactory. The method of preparation of the marrow is described on p. 199.

The condition most improved is chlorosis, but it is claimed that some cases of pernicious anaemia have been helped.

Most anaemic patients have no appetite, or lose it, during the early part of the day, and careful attention should therefore be given to making all their food as agreeable to them as possible in taste and manner of serving. Meat should be prepared so as to require the least possible effort in mastication, and much more food can be consumed in a fluid and semisolid form.

Condiments are serviceable, for they render simple food more agreeable and stimulate the enfeebled gastric secretion. Moleschott insists on the free use of salt by chlorotic patients on account of its supposed favourable action in restoring the blood corpuscles and plasma. Vinegar, pickles, gravies, and sauces should be avoided.

Alcohol is not indicated for all, but there are some patients who are benefited by its use, and the best form of alcoholic tonic for an anaemic patient is a good rich claret, Burgundy, or Madeira. Some of the milder cases, especially in women in whom the digestive organs are not particularly disturbed, do very well on porter or stout, or one of the various malt preparations, which may be taken with the noonday meal or at bedtime with a few crackers or a raw-beef sandwich. The latter is a prescription very serviceable in those cases in which insomnia is a harassing symptom. There is no apparent connection whatever between the absorption of alcohol and the formation of new blood cells, although there is a popular idea to the effect that red wine produces red blood. Alcohol, however, often does promote the accumulation of fat, and this is most undesirable in anaemic subjects who already possess that tendency.