Pernicious or idiopathic anemia is essentially a disease of adult life. The cause is unknown; recent advances in our knowledge point to its being, in the vast majority of cases, the result of a chronic absorption of poisons from the intestinal tract. The history of the case usually reveals some gastric intestinal disorder - constipation, flatulence, deranged appetite - which has been induced or aggravated by a septic condition of the teeth and mouth (oral sepsis). An examination of the stools shows them to be unformed and foetid in character. The disease is a serious one, and frequently fatal. Diet is a very important factor in treatment The following points are essential adjuvants in treatment: -

1. Complete rest in bed is essential.

2. Careful attention should be directed to the state of the mouth and teeth. All septic stumps should be removed, and an antiseptic mouth-wash used daily.

3. The bowels should be thoroughly cleaned out by the aid of one or two doses of calomel, followed by salts or by enemas of soap and water.

4. The use of medicinal agents which arrest abnormal bacterial activity in the intestinal tract is usually indicated. These include various preparations of lactic acid bacilli - eg., Lacto-bacilline, Sauerin, and, to a lesser extent among drugs, salol, sulpho-carbolate of soda, and calomel.

Dietetic Treatment

The diet has to be adapted alike as to the amount and nature of the foodstuffs used, to the impaired state of digestion, to the chronic catarrhal condition of the bowel, and to the correction of the abnormal bacterial activity in the small and large intestines, which are so important features of the disease. The indications for treatment are therefore the following: -

1. Foodstuffs must be of an easily digestible nature.

2. Farinaceous foods to be restricted, because of their liability to undergo abnormal fermentative changes.

3. Protein foods to be selected with care, so as to diminish putrefactive changes in the bowel.

The degree of bacterial infection from the bowel depends very largely on the amount of foodstuffs available for them. The multiplication and activity of the bacteria will be proportionate to the amount of foodstuffs presented to them. The aim in treatment is to give a diet of such size and quality as will be rapidly digested and absorbed, thus arresting abnormal bacterial activity in the small and large intestines.

In Severe Cases Associated With Gastro-Intestinal Derangement

For the first few days a much restricted diet is advantageous. One and a half pints of skimmed milk, 1 1/2 pints of soured milk, and 1 pint of a meat tea, with two slices of crisp toast or unsweetened rusks, in the twenty-four hours, is a useful dietary for the first few days. This diet is best administered in quantities of 8 to 10 ounces every three hours. Under the influence of this regimen the appetite improves, the abdominal discomfort or pain abates, and the state of the motions becomes more satisfactory. The diet is then cautiously increased. This may be done by the gradual addition of easily digested protein in the form of white of egg, fresh milk, raw-meat juice, either prepared at home or the various meat juices in the market, Wyeth's, Liebig's peptone, etc, or one of the various malted foods, and raw oysters.

Animal food in the form of fish, chicken, sweetbread, pheasant, partridge, rabbit, or tripe; and puddings in the form of sweet jell)', milk jelly, blancmange, lemon sponge, curds, or custard are then added to the dietary. Plain milk puddings should come later, as they are a greater tax on the digestion than those mentioned. Fruit juice may be given in the form of refreshing beverages (p. 275). Special care must be taken with regard to the increase of the farinaceous foods and of vegetables. Simplicity in the meals gives the keynote to successful treatment. In cases associated with acute febrile disturbance it may be necessary to have recourse temporarily to the fever diet described on p. 268.

The following diet sheets may be recommended as being appropriate for a case of an adult man of average size, to be commenced after the few days' fluid dietary recommended above: -

6 a.m. - Milk, 10 ounces (hot or cold).

8 A.M. - Cup of Benger's food made with milk, a little milk to drink, and a crisp slice of toast.

11 A.M. - Soured milk, 10 ounces; dry rusk.

1.30 P.M. - Beef-tea, chicken essence, etc., strengthened by the addition of white of egg, Protene, Plasmon, or Sanatogen, or by the addition of 1/4 lb. raw scraped beef; slice of crisp toast or a roll.

4 P.M. - Cup of milk, or cup of tea made with boiling milk.

6 P.M. - Cup of buttermilk, with slightly sweetened biscuits.

8 P.M. - Cup of Allenbury's or Benger's food made with milk; or Cup of Horlick's malted milk made with milk, and a slice of dry toast.

In cases with atony of the stomach and bowel with dilatation of the stomach, and also in cases complicated with renal disease and dropsical tendency, a very much smaller amount of liquid must be given and food must be administered in a more concentrated form, as in the following diet list: -

6 A.M. - Chicken essence or jelly, 6 ounces; half-slice of toast. 8 a.m. - Cup of invalid food; add to this white of egg, well beaten. 11 A.M. - Soured milk, 10 ounces, and a plain dry biscuit.

I.30 P.M. - Fish or chicken souffle, or scraped beef mince. Half-slice of toast.

4 P.M. - Cup of tea made with milk, 6 ounces. 6 P.M. - Soured milk, 10 ounces, and a plain dry biscuit. 8 P.M. - Beef-tea, or strong soup thickened with egg and a little milk, or Plasmon, or Protene.

Later, when the gastro-intestinal condition has improved as shown by the state of the tongue, the return of appetite, and the more normal state of the motions, the diet must be made more liberal and varied, as follows: -

6 A.M. - Cup of tea made with milk, or a glass of hot milk. 8 A.M. - White fish, or lightly boiled fresh egg. 1/2 pint hot milk.

Slice of crisp toast, or roll with butter; no jam or marmalade. 11 a.m. - Soured milk, 1/2 pint, with biscuit. 1.30 P.M. - Clear soup, or meat tea, 10 ounces.

Fish, chicken, game, sweetbread, rabbit, or tripe, simply cooked.

Half-slice toast, or rusk.

Pudding, to be preferably jelly, curds, custard, or a little stewed fruit with cream. Tablespoonful of whisky, or glass of wine if desired.

4 P.M. - Cup of tea or peptonised cocoa, made with milk; one small piece of plain breadstuff. 6 P.M. - 1/2 pint of soured milk and a biscuit. 8 P.M. - Fish or chicken souffle, slice of toast or roll, glass of milk.

After eight or ten days of the above dietary it will usually be found that there has been a further improvement in the state of the digestive tract, shown by the complete disappearance of subjective symptoms, and a further improvement in the state of the stools. The total amount of food may now be increased, but the diet should be maintained along the lines indicated. Farinaceous puddings, thick soups, pastry, and rich foods of all kinds should be avoided, or, at most, given in the most sparing amount.