Fat and Blood / An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria

by S. Weir Mitchell

It is difficult to treat any of these cases without a resort at some time more or less to the use of milk. In most dyspeptic cases—and few neurasthenic women fail to be obstinately dyspeptic—milk given at the outset, and given alone by Karell's method for a fortnight or less, enormously simplifies our treatment. Even after that, milk is the best and most easily managed addition to a general diet. As to its use with rest and massage as an exclusive diet in obesity alone or in extreme fatness with anæmia, I spoke in a former edition with a confidence which has been increased by the added experience of physicians on both sides of the Atlantic. Finally, there are exceptional cases of intestinal pain of obscure parentage or seemingly neuralgic, of dyspepsia incorrigible by other treatments, which, having resulted in grave general defects of nutrition, are best treated by several weeks of milk diet, combined with rest, massage, and electricity. Milk, therefore, must be so much used in these cases in connection with the general treatment I am describing that it is perhaps as well to say more clearly how it is to be employed when given alone or with other food. I am the more willing to do this because I have learned certain facts as to the effects of milk diet which have, I believe, hitherto escaped observation. In fact, the study of the therapeutic influence and full results of exclusive diets is yet to be made; nor can I but believe that accurate dietetics will come to be a far more useful part of our means of managing certain cases than as yet seems possible.

We are indebted chiefly to Dr. Karell, of St. Petersburg, for our knowledge of the value of milk as an exclusive diet, and to Dr. Donkin for the extension of Karell's treatment to diabetes. I shall formulate as curtly as possible the rules to be followed in using milk as an exclusive diet in dyspeptic states, and in anæmia with obesity, and in the latter state uncomplicated by defective hæmic conditions.

For fuller statements as to the reasons for the various rules to be observed in using milk, I must refer the reader to Karell's paper and to Donkin's book.

Have the utmost care used as to preservation of the milk employed, and as to the perfect cleansing of all vessels in which it is kept. Use well-skimmed milk, as fresh as can be had, and, if possible, let it be obtained from the cow twice a day. Or if this is not possible, or where any doubt exists as to the condition of the milk, or any difficulty is experienced in keeping it fresh, it may be pasteurized as soon as received by heating it to 160°, keeping it some minutes at this point, and at once chilling on ice. For this purpose it is best to have the milk in bottles, and to heat by immersing the bottles in a water-bath. For longer preservation, as, for example, when travelling, sterilizing may be more thoroughly done by greater heat and lengthened immersion. Still, these should be expedients for use only when milk cannot be secured fresh and in good order, as it is more than doubtful if the milk is so well borne when it has been altered by these processes.

For ordinary daily use it might be better to let all the milk for the day be peptonized in the morning with pancreatic extract, to the extent which is found to be agreeable to the patient's taste, and then preserve it by placing it upon ice. In this way milk may be kept for several days. Then, too, it has been found that where even skimmed milk upsets the stomach of patients, milk prepared in this manner can be taken without trouble. In peptonizing, the directions which accompany the powders to be used for that purpose should be followed carefully. It is to be remembered that if the patient desires to take the milk warm, the process of conversion into peptones, which has been stopped by the cold, will be promptly started again when the fluid is warmed, and then a very few minutes will suffice to make it disagreeably bitter. At first the skimming should be thorough, and for the treatment of dyspepsia or albuminuria the milk must be as creamless as possible. The milk of the common cow is, for our purposes, preferable to that of the Alderney. It may be used warm or cold, but, except in rare cases of diarrhoea, should not be boiled.

It ought to be given at least every two hours at first, in quantities not to exceed four ounces, and as the amount taken is enlarged, the periods between may be lengthened, but not beyond three hours during the waking day, the last dose to be used at bedtime or near it. If the patient be wakeful, a glass should be left within reach at night, and always its use should be resumed as early as possible in the morning. A little lime-water may be added to the night milk, to preserve it sweet, and it should be kept covered.

The milk given during the day should be taken at set times, and very slowly sipped in mouthfuls; and this is an important rule in many cases. Where it is so disagreeable as to cause great disgust or nausea, the addition of enough of tea or coffee or caramel or salt to merely flavor it may enable us to make its use bearable, and we may by degrees abandon these aids. Another plan, rarely needed, is to use milk with the general diet and lessen the latter until only milk is employed. If these rules be followed, it is rare to find milk causing trouble; but if its use give rise to acidity, the addition of alkalies or lime-water may help us, or these may be used and the milk scalded by adding a fourth of boiling water to the milk, which has been previously put in a warm glass. Some patients digest it best when it has the addition of a teaspoonful of barley-or rice-water to each ounce, the main object being to prevent the formation of large, firm clots in the stomach,—an end which may also be attained by the addition at the moment of drinking of a little carbonated water from a siphon. For the sake of variety, buttermilk may be substituted for a portion of the fresh milk, and though less nourishing it has the advantage of being mildly laxative.

When used as an exclusive diet, skimmed milk gives rise to certain very interesting and what I might call normal symptoms. Since at first we can rarely give enough to sustain the functions, for several days the patient is apt to lose weight, which is another reason why exercise is in such cases undesirable. This loss soon ceases, and in the end there is usually a gain, while in most rest cases an exclusive milk diet may be dispensed with after a week. Where milk is taken alone for weeks or months, it is common enough to observe a large increase in bodily weight. I have seen several times active men, even laboring men, live for long periods on milk, with no loss of weight; but large quantities have to be used,—two and a half to three gallons daily. A gentleman, a diabetic, was under my observation for fifteen years, during the whole of which time he took no other food but milk and carried on a large and prosperous business. Milk may, therefore, be safely asserted to be a sufficient food in itself, even for an adult, if only enough of it be taken.

During the first week or two, exclusive milk diet gives rise to a marked sense of sleepiness. It causes nearly always, and even for weeks of its use, a white and thick fur on the tongue, and often for a time an unpleasant sweetish taste in the early morning, neither of which need be regarded. Intense constipation and yellowish stools of a peculiar odor are usual. Of the former I shall speak in connection with the use of milk in special cases. The influence of milk on the urinary secretion is more remarkable, and has not been as yet fully studied.

There is, of course, a large flow of urine; and in dropsical cases due to renal maladies this may exceed the ingested fluid and carry away very rapidly the dropsical accumulations. It is sometimes annoying to nervous persons because of the frequent micturition it makes necessary. I have discovered that while skimmed milk alone is being taken, uric acid usually disappears almost entirely from the urine, so that it is difficult to discover even a trace of this substance; nor does it seem to return so long as nothing but creamless milk is used. Almost any large addition of other food, but especially of meat, enables us to find it again. Creatine and creatinine also seem to lessen in amount, but of the extent of this change I am not as yet fully informed.