Many cases of chlorosis are associated with marked subjective symptoms of gastric disturbance, such as sensation of weight after food, flatulence, pain in the epigastric regions, and vomiting, and in these cases the possibility of the coexistence of a gastric or duodenal ulcer has to be borne in mind. In the majority of cases, however, these symptoms are absent. The treatment of these two different groups will now be considered in detail, but reference may first be made to certain preliminary essentials in the treatment of all cases, viz.: -

1 Baked bread is prepared by cutting a loaf of stale pan bread very thin, dipping the slices in milk, and placing in a cool oven to become thoroughly crisp and of a light brown colour.

1. A thorough clearing-out of the bowels by a judiciously selected course of aperients, or enemata of soap and water, or soap and water following small injections of olive oil. Frequently-administered enemata may be required to completely remove the scybalous masses which are so frequently present in cases of anemia. After the bowels have been cleared out, some tonic aperient medicine, e.g. cascara, should be administered daily.

2. Careful attention to the condition of the mouth and teeth. - A septic condition of the mouth and teeth is frequently present in chlorosis, and this should be remedied by appropriate means, the assistance of a dental surgeon being called in, if necessary, to get the mouth into a satisfactory condition.

3. Complete rest in bed. - In all pronounced cases, complete rest in bed for at least three to four weeks is essential to a speedy and complete recovery.

Chlorosis With Pronounced Gastric Irritation

In this condition there is marked hyperesthesia of the gastric mucous membrane, sometimes associated with an excessive production of hydrochloric acid. The indications for treatment are therefore - (1) To give the stomach rest by giving easily digested food in very small quantity at a time, or it may be by withholding food altogether for twenty-four or forty-eight hours, nutrient enemata being substituted; and (2) Administering an alkali, e.g., bicarbonate of soda, 10 to 30 grs., with fluid nourishment. These indications are fulfilled in the following manner. Milk should be the staple dietary, and should be given diluted with potash, soda, lime-water, Vichy or Apollinaris water, 1 ounce of milk being given every hour. In some cases it may be advisable to give the milk peptonised. The amount of milk and the proportion of milk should be gradually increased until the patient is taking from 4 to 5 pints of milk in the twenty-four hours. This is best given in the form of 8 to 10 ounces every three hours.

As soon as the gastric symptoms have subsided, other nourishment may be given, chiefly in the form of bread-stuffs - dry toast, rusks, Vienna rolls, Veda bread; meat juice and beef-tea preparations, and lightly malted invalid foods, such as Savory & Moore's, Benger's, and Allenbury's food. These should be followed by simple farinaceous food, such as semolina, ground rice, arrowroot, and cornflour. The recently introduced preparations of "Puffed rice" and Granose flakes make an agreeable change to many patients. Protein foods should be gradually added to the diet; eggs, souffles, fish - steamed whiting, plaice, and flounders are the lightest - sweetbread, chicken, fresh game, rabbit; later, mince, beef quenelles, and steak, the patient gradually passing on to the convalescent diet, fully described on page 387. If flatulence is a prominent feature, special care must be taken with the vegetables, the most suitable ones being cauliflower, spinach, and Portugal onions, potatoes being withheld until digestion is stronger. Of the pulses, lentils may be given on account of their richness in iron; the pulses, as a whole, however, are not very easily digested by these patients. At the end of four to six weeks, if the condition of the blood is now improved, the patient may pass to an unrestricted physiological diet, special warning being given against the immoderate use of tea, any deficiency in protein and fat elements of food, and an excess of carbohydrates often in unsuitable forms. The addition of moderate quantities of fresh fruit and vegetables is of value both in general nutrition and for assisting to correct the tendency to constipation.

Dietary In Chlorosis, Associated With Gastric Derangement

Chlorosis Without Much Gastric Disturbance

Rest in bed, attention to the toilet of the mouth, and the cure of constipation, already referred to, are of prime importance in treatment. After the first few days, when the bowels have been thoroughly cleared, the patient can be placed on a full convalescent diet - which includes meat, eggs, good soup; in the vegetable kingdom, lentils contain a relatively large amount of iron, and can be judiciously made use of in the dietary.

7 A.M. - Uncooked fruit - apples, figs, prunes, or raisins.

Breakfast

Sauccrful of porridge, with cream and milk.

Fish, egg, tongue, bacon, ham.

Cup of tea, with plentiful supply of milk.

11 a.m. - Cup of milk, or small cup of soup.

Lunch (two-course)

1. Freshly-cooked fish, chicken, rabbit, sweetbread, red meat, with vegetable.

2. Milk pudding, with stewed fruit.

Tea

Cup of tea (made with milk), bread and butter. No new scones.

Dinner (three-course meal)

Freshly-cooked meats, with one vegetable.

Simple pudding or savoury.

Soup,

Fish,

Pudding.

Meat,

Pudding,

Savoury.

Soup, Meat, Pudding.

Fish,

Pudding,

Savoury.

10 P.M. - Milk, one cup, with Horlick's malted milk.