light food, such as a cup of cocoa or of warm milk should be taken in the morning before dressing. Without this precaution the patient is too much exhausted after the bath and the fatigue of dressing, to have any appetite for breakfast. With returning strength and the ability to take larger quantities of food at regular meal-times, the intermediate supplies of the forenoon and evening may be gradually diminished and dispensed with.

Alcohol. Allusion has already been made to the importance of excluding, in these cases, from the dietary alcohol in every form. It must be granted, however, that, where the digestive functions have for a long time been seriously impaired, and there is much consequent weakness, a limited amount of alcohol will be necessary.

Light Wine.-The form in which it is least objectionable is that of a light wine, and the patient may be allowed to take with the midday meal and with supper a glass of claret, of light burgundy, of hock, or of chablis. Experience proves that patients of this class who are able to spend a considerable portion of time in the open air, and to take a reasonable amount of exercise, do better on an entirely non-alcoholic diet.

Slighter Cases. In cases where things have not gone to extremes, where friends and attendants have not altogether lost control of the patient, judicious management, together with properly regulated exercise and a diet such as that sketched above, will often work wonders in the treatment of hysterical patients.

"Weir-Mitchell" Treatment.-When, however, there is great emaciation and serious depression of nerve power, it is to what is generally known as the Weir-Mitchell plan of treatment that we now turn in the hope of benefiting these patients. The combined nature of this treatment must not be forgotten-rest, isolation, massage, large quantities of food, and electricity. Without strict isolation and complete rest, little good will be obtained, and without

massage properly carried out, the large quantities of food cannot be digested or assimilated.

Isolation. By separation from friends and ordinary surroundings, old and often hurtful associations are broken up, and the worried nervous system is put at complete

rest.

Massage. The massage, with or without electricity, takes the place of exercise, and the amount can be regulated from time to time as the physician finds necessary to suit the requirements of the particular case. By means of systematic massage the elimination of waste products is greatly stimulated, and a steady building up of healthy tissue takes place, the ultimate result being a vast increase in both muscular and nerve power.

Selection of a Nurse.-The first important conditions of success are the selection of a suitable and reliable nurse, and of a bright airy room with a good exposure. These are matters of the greatest importance, when it is considered that the patient must remain in bed absolutely for at least three or four weeks from the beginning of the treatment, and that all communications with the outer world are practically cut off. Before commencing treatment, the patient's weight should be ascertained, and may be taken at intervals during the course.

Milk Alone at First.-At first the food given should be milk alone, with the exception, perhaps, of a small cup of black coffee early in the morning, if required to obviate a tendency to constipation. The milk will generally agree best if it be slightly warmed, but unless there be diarrhoea it need not be boiled. For the first day or two, give every two hours from three to four ounces of milk, which will bring the total quantity in the twenty-four hours to about two pints, allowing for the intervals of sleep.

Amount of Milk.—The amount given at a time should be gradually increased, and the interval lengthened to three hours, the total being brought up to two quarts. The

milk should be sipped very slowly, and if it be very distasteful to the patient, as is the case in rare instances, it will be necessary to add enough tea, coffee, or cocoa just to flavour it. In other cases where milk is at first badly borne, though happily these also are rare, the difficulty may be got over by giving milk with a lessened amount of ordinary food, and gradually increasing the quantity of milk until it becomes the sole diet.

Alkalies with Milk.-Alkalies with milk will be needed only in those cases where it sets up much acidity. After two or three days alternate supplies of five and ten ounces every three hours will usually be well borne. Soon ten ounces every three hours can be taken with ease, and we shall next proceed to add for breakfast a cup of cocoa with bread and butter, and in the middle of the day a milk pudding. Fish or chicken will next be added, first either at the midday or evening meal and then at both. The diet will, therefore, stand thus:

Milk.-Sixty to eighty ounces.

Breakfast.-Cocoa and bread and butter.
Luncheon.-Fish, vegetable, and pudding.

Dinner.-Chicken, vegetables, and bread.

In most cases, after a few days of this diet further additions may be made as follow, still keeping up the full quantity of milk.

Breakfast.-Porridge and cream early in the morning. Second Breakfast.—Cocoa and egg, bread and butter. Luncheon.-Fish, bread, pudding and milk; or chicken, vegetables, and pudding.

Dinner.-Mutton or beef, two or three kinds of vegetables, milk-pudding, or stewed fruit with cream.

Extract of Malt may be given with one or more supplies of milk during the day, and if strong soup and beef peptonoids are used, they will take the place of one of the supplies of milk.

Cod-Liver-Oil and Iron are useful adjuncts in some cases, and other tonics, as acids, quinine, and strychnia, given

towards the close of the treatment, may be usefully continued for some time afterwards.

Gradual Reduction of the Diet.-At the end of five or six weeks the slackening off of this excessive diet is commenced by reducing the quantity of milk, and as the patient comes to take more exercise, the massage also is lessened.

Increase in weight and muscular power are the best tests of the efficiency of the massage. If the result be not satisfactory in these two important respects, it is high time to inquire closely into the way in which the massage is being carried out.

After Treatment.-When the term of treatment is concluded, the patient should lead an active open-air life, but for some months longer a daily rest of two or three hours should be inculcated. The return to ordinary diet must be made gradually, by leaving off the intermediate supplies of food one by one.

In this way the system by degrees adapts itself to the change. A sea-voyage or a prolonged tour in many cases confirms the cure. Relapses happily are uncommon, especially where this treatment is followed by a life of active usefulness.

CHAPTER XVI.

DIATHETIC DISEASES.

GENERAL CONTENTS: Fevers (except Typhoid Fever)—Acute Pneumonia, &c. -Typhoid Fever-Use of Alcohol in Fevers.

FEVERS (EXCEPT TYPHOID FEVER, see p. 142)—ACUTE PNEUMONIA, &c.

THE teaching of Graves marks a revolution in the dietetic treatment of fevers. A great reaction then set in against starving in acute diseases accompanied by fever, and since that time the danger has been more on the side of overfeeding than of under-feeding.

Precise Directions.-Unless precise directions are given by the physician, anxious friends, and even nurses, who should know better, are apt to push the quantity of food too far, thereby oftentimes adding to the discomfort of the patient, if they do not actually endanger his life or retard his

recovery.

A very prevalent idea is that if the patient be restricted to beef-tea, broths, and milk, these foods may be given practically without limitation, to make up for increased metabolism and loss of nitrogenous materials consequent on the feverish state. Undoubtedly the difficulty in not a few cases is to get the patient to take a sufficiency of nourishment; but, on the other hand, the unlimited administration of food in cases where the patient will take it is as reprehensible as the plan of starvation.

Several general points should here be noted in regard to