I give instead a mixed diet, which in cases of disturbances of digestion at the beginning follows exclusively Leube's diet-sheets arranged for patients with gastric ulcer.++ Among these is unskimmed new milk in large quantities for such cases as can take it, and a certain amount is always given. Besides this the patient is given eggs, chicken, sweetbreads, pigeon, brains, minced or scraped beef (raw or grilled), roast beef, beefsteak, venison. Good butter is also allowed in most cases. Carbohydrates are represented by wheaten bread (not too fresh), well-cooked rice, mashed potatoes, and macaroni. To the extent to which the patient is free from dyspeptic or other digestive symptoms the list is extended by other things, such as fish (except salmon and eel), oysters, cooked fruit, etc. The patient has four meals a day, divided by about four hours, e.g., at 8 a.m., 12 noon, 4 p.m., and 8 p.m. The milk is given in small quantities during the day with and between meals.

* If we take unskimmed milk as containing 3.5 per cent. proteid, 35 per cent. fat, and 5 per cent. milk sugar, which is fairly accurate, and, further, if we take the net value per gram of the three different foodstuffs to be respectively 3.2, 84, and 36 calories, we find that a litre of this milk gives under 600 calories. (Milk sugar is below the average for carbohydrates; its value is 36 calories). Since in the Weir-Mitchell treatment, which in the case of a thin patient aims at fattening, we wish to give the patient at rest at least as many calories as a person doing average mechanical work, say, 35 calories for each kilo body weight, we find, e.g., that a patient of 70 kilos weight, in order to receive the necessary 2,450 calories from exclusive milk diet, must drink over 4 litres unskimmed milk in twenty-four hours, which would not appreciably increase his fat. If skimmed milk were drunk over 6 litres would be required ! But how many people are able to drink that quantity without dyspeptic symptoms ? Those who, in spite of daily experience, obstinately persist in the belief concerning the excellence of cow's milk compared to all other food should consider two facts stated by Rubner : (1) That cow's milk, which is suitable for children, falls short by 8 to 12 per cent. of the nitrogen required for an adult; (2) that the deficit in nitrogen is more serious when milk is given alone without other foods.

+ Weir-Mitchell (in his fourth edition) gives at first milk only to those thin neurasthenic patients whom alone I should consider suitable cases for the treatment (e.g., 120 grm. every other hour). Very soon mixed diet is given, and after ten days the patient receives three meals daily and from 60 to 120 grm. malt extract before every meal. Weir-Mitchell also gives iron as soon as the exclusive milk diet ceases, and from the third week, in severe cases, also cod-liver oil (15 grm. after meals, by the mouth or rectum). Later he nearly always gives strychnine, and sulphur with iron or arsenic. For my part I have never used exclusive milk diet other than for a few nephritis patients, where the chief object is to lessen the work of the kidneys, and where with this diet we often obtain very good results, which are easily understood when one considers the marked changes in the urine which occur on this diet.

+ Instead of all these things being added successively to the diet, as in the case of a patient suffering from gastric ulcer, patients undergoing Weir-Mitchell treatment take them all at once and in larger quantities.

The patient should take no alcoholic drink, or, if any at all, only small quantities of Pilsner, claret, cognac, or whiskey; the two last are often given in milk.

So far I have never needed to give aperients during Weir-Mitchell treatment. If abdominal kneading is well done they should very rarely be necessary.

Throughout the cure the patient usually sleeps well, even in those cases where insomnia was present. Formerly I usually avoided giving narcotics; latterly I have sometimes used veronal in small doses and combined with sodium bromide. Neither veronal, sulphonal, nor trional are so harmless as they are said to be, and they are bad for the heart. I do not care to give more than .5 grm. for one dose, preferably with 2 grm. sodium bromide.

The cure allows of treatment with iron at the same time; this also depending upon the abdominal massage. If necessary I alternate the different preparations. I have, however, made use of Levico water containing both iron and arsenic. Roncegno is also good, but varies very much in the quantity of minerals it contains.

General massage is given; the most important object in the cure is as far as possible to let massage take the place of exercise, and prevent those discomforts which would arise through the patient's lying in bed so long.

Concerning the technique there is nothing further to say than that abdominal kneading and tapotement of the muscles should be as thorough as possible, the latter as hard as the patient can bear without being irritated or unpleasantly affected by it, which point varies much. The head is always left alone. Massage can well be given twice a day, always at least once for three-quarters of an hour. The doctor has rarely time to do it himself, but can leave it to some trained person of the same sex as the patient.

General faradisation is given with slow intermittent current because of its well-known influence on muscles and nerves and its general tonic effect. The special muscles are first treated, then one electrode is placed at the back of the neck, and the other for a quarter of an hour first on the sole of one foot and then on the other. According to Weir-Mitchell electricity is the least important part of the treatment. This opinion I had already formed before reading Weir-Mitchell's work, after I had several times tried his well-known cure with excellent results, without once using electricity.

Instead, I order the patient to take a "sponge bath" each morning on waking, i.e., to be sluiced all over with a large sponge with moderately cold water. The temperature is preferably just over 20° C, and I generally tell the patient that the water must feel cold and bracing, but not disagreeable. It is best to use a "sitz bath."

Women usually start the cure immediately after menstruation.