It is very important to thoroughly cleanse the mouth after drinking the milk, in order to avoid coating of the tongue and the disagreeable taste which destroys the appetite and interferes with the efficacy of the treatment. For a full discussion of this subject the reader is referred to the article on milk diet in typhoid fever (p. 432). Obstinate constipation, which almost invariably results from a long-continued milk diet, must be met by medicinal treatment, or the use of glycerin suppositories or enemata. As a rule, the milder laxatives are the only remedies necessary; a glass of citrate-of-mag-nesia solution, a half tumblerful of bitter water taken on rising in the morning, a drachm of the compound-licorice powder, or a two-grain pill of extract of cascara sagrada at night, will prove sufficient. There is, however, no objection in most cases to allowing the use of a few stewed prunes or the soft part of two or three baked apples.

It will be observed that whereas the normal average quantity of urine for an adult male is fifty-two ounces for the twenty-four hours, the milk diet under discussion requires the ingestion of upward of one hundred ounces of fluid. This necessitates greatly increased activity of the kidneys, but the polyuria usually results in the removal of the anasarca which frequently exists. The body weight may remain normal, or even be slightly increased on this treatment. It is not infrequently diminished, however, but much depends upon the condition of the patient at the time when the milk diet was inaugurated. The abundant urine is of a pale-yellowish hue, which is somewhat typical of the milk diet. The specific gravity is low, and the reaction may be neutral or faintly acid on account of the great dilution of the fluid. The albumin, which at first may be present in considerable bulk - sufficient when coagulated to almost solidify the contents of the test tube - gradually diminishes, and the urea and salts increase. In mild cases this milk diet should be continued from four to eight weeks, after which a slight variation may be allowed in the shape of farinaceous food, fresh vegetables, and fruit, such as oranges and lemons.

In other cases it may be necessary to prolong the treatment for several months, because it will be found that any attempt to materially alter the diet is followed by an increase in the albumin and dropsy, with return of other symptoms. In such patients the lesion of the kidney is far advanced and incurable, and the most that can be hoped for from any treatment is an amelioration of the worst symptoms, and it is found that in many cases this can be best secured by milk diet. For the class of cases in which this treatment is found for any reason to be impracticable, either from the persistent refusal of the patient to take milk or from any other cause, before giving up its use efforts should be made to modify its preparation in various ways, tempting the patient with different flavours and with light farinaceous foods, of which milk forms an important basis, such as bread and rice puddings. A good deal of milk may be taken in very weak coffee or tea, or in the form of soups and purees made with celery or potatoes, or gruels may be given, or milk thickened with tapioca, vermicelli, sago, or rice, and flavoured with a little lemon or orange peel, cloves, or allspice.

It is not desirable to use much high seasoning for fear of irritating the diseased kidneys.

As the patient improves, the milk diet may be given up, but it should never be too suddenly abandoned. A sudden restriction of fluids in chronic nephritis is always injurious, and their quantity should be regulated by the vascular tension. In adopting any other diet it is a good rule never to let the nitrogenous food bear a greater proportion to the non-nitrogenous than one to four. The former increases the proportion of urea in the urine, the latter reduces it. A purely vegetable diet has often been tried for albuminuriacs, but it causes too pronounced anaemia if its use is persisted in, and a minimum of animal food must therefore be prescribed. Granger Stewart says, in speaking of the very chronic albuminuria of Bright's disease, "In the more advanced stages the diet should be as nutritious as possible, and then certainly fresh meat is by no means injurious." With failing cardiac compensation the heart muscle may give out unless meat be eaten.

When, after a milk diet, the change is to be made to a more liberal menu, the hours of taking the milk may be reduced in frequency, and some of the milk may be replaced by boiled fish, chicken, or game, and fresh green vegetables, potatoes, cream, butter, and bacon. Cereal foods may be eaten ad libitum, such as hominy, corn bread, oatmeal, sago, tapioca, rice, vermicelli, bread pudding, and macaroni. Cheese may be eaten occasionally. The urine should still be periodically examined, and if it is found that the eating of meat is followed by an increase in the albuminuria the patient must return to the milk diet.

It not rarely happens that strict adherence to a milk diet for several weeks produces more lasting improvement in the action of the kidneys, so that a diet to which steak, roast beef, chops, and eggs are admitted may not only be well borne, but may increase the strength of the patient. This is a matter which obviously cannot be regulated by fixed rules. If the general principles of the treatment are understood, it is within the province of any intelligent physician to apply them to individuals. In cases in which it is found after trying all methods that milk cannot be assimilated in any form, the patient must live upon a carbohydrate diet, consisting of fresh vegetables and fruits, with butter, cream, and olive oil. Dujardin-Beaumetz allows pork and ham to be eaten by those who refuse to relinquish meat entirely.

Senator believes that whenever serious albuminuria is present egg albumen and meat should be withheld, although a little fish or flesh, like that of chicken or veal, may be given if necessary, but he prefers to prescribe only vegetables, salads, and fruits, or an exclusive milk diet of two litres per diem.

Semmola recommends the use of the following drink, which may be mixed with milk, and which possesses a decided diuretic action:

Sodium iodide..........................................15 grains.

Sodium phosphate ......................................30 "

Sodium chloride.........................................90

Drinking water.........................................36 ounces.

In general, the patient had better leave alcohol alone, especially in the form of malt liquors. If habituated to its use, a feeling of dulness and drowsiness after a glass of wine is a strong reason for giving it up. An occasional "spree " may do the patient less harm than continued drinking in smaller quantity. For a non-alcoholic subject, if weak and anaemic, as he improves, a little light wine or claret diluted with Seltzer water or Apollinaris may be ordered as a beverage. Tea, coffee, and cocoa are permissible.

The effect of dietetic treatment will be much enhanced by securing systematic outdoor exercise, and freedom from worry and anxiety, and particular attention must be paid to keeping the bowels open, for which laxative fruits may be taken freely. The patient must be cautioned against overeating, and all food must be thoroughly masticated.