Aside from deciding between permissible and non-permissible articles of food and prescribing the proper quantity of proteid and fluids, dietetic treatment in contracted kidney must concern itself with the very important problem of the total amount of nutriment to be given. As we all know, the fat content of the body is dependent on the latter factor. Obesity is a grave complication in Bright's disease. Both conditions endanger the heart; when they are combined the danger is doubled. In the case of patients with contracted kidneys, as in cardiac patients, a reduction cure should be decided upon much sooner than in healthy persons with a like adiposis.

These rules are often transgressed in practise; many nephritic patients are met with who were formerly thin or in a normal state of nutrition, but who have become so stout as the result of an unsuitable diet (much milk, butter, farinaceous foods, bread and vegetables), that they must be classed as obese. While they were formerly in a healthy condition in spite of their albuminuria, a variety of secondary cardiac disturbances have appeared with the obesity, more especially stenocardiac attacks; these, provided that the disease has not progressed too far, may disappear if the accumulation of fat can be appreciably diminished.

Such a case is described in my monograph on "Obesity" (Nothnagel's "Special Pathology and Therapy," page 100, Vienna, 1900).

The patient was an official of forty years in whose urine an abundant quantity of albumen was found when he was examined for life-insurance. At the time of the examination he was enjoying the best of health. His physician made the diagnosis of "contracted kidney" and was undoubtedly correct; he prescribed a diet containing no meat nor eggs and consisting largely of abundant quantities of milk and farinaceous food. In the course of three months the patient gained many pounds, his weight increasing from 130 to 170 pounds; at the same time he developed attacks of asthma and several times during the night suffered from stenocardiac seizures. He was in this state when I saw him for the first time. The apex of the heart extended 15 cm. beyond the median line. The degree of albuminuria equalled 0.03 per cent, and was therefore about the same as at the onset of the disease or rather at the time when the disease was discovered (at that time according to the analysis that the patient showed me it was 0.033 per cent.) I prescribed restriction of fluids to 5-4 of a liter; at the same time I interdicted the use of the diet he was taking and substituted a diet containing fewer calories (about 25 calories pro kilo); he was also given cold rubs and later advised to undergo a course of treatment in Homburg. The results were excellent; within six weeks his weight was reduced to about 150 pounds and at the expiration of another ten weeks to 135 pounds; his albuminuria, of course, persisted, but the distressing symptoms had all disappeared, the apex was three centimeters nearer to the median line and the patient thus escaped the great danger of paralysis of the heart that was threatening. In the Summer of 1901 I had occasion to examine this patient again; his weight had remained stationary between 135 and 140 pounds; he suffered no distress from the heart during the whole intervening time; the apex beat was found 12 cm. exterior to the median line.

It will be seen from all that has been said that overfeeding is dangerous in contracted kidney. Enough food should of course be administered to maintain the nutrition of the patient, but a medium amount of nourishment should never be exceeded. In cases in which it seems desirable to attempt a reduction of excessive fat, reduction cures should of course be instituted only with the greatest care. The main object is not to obtain rapid but good results. For this reason it is well to adhere to the dietary regulations that are indicated during the first stage of a reduction cure and not to carry dietary restrictions beyond this point; the diet should be limited to about 4-5 of the diet needed to maintain the patient in statu quo according to calculation (for a scale of dietetic cures in obesity, see von Noorden, "Obesity," page 11 off. Vienna, 1900). Only in exceptional cases may we proceed to the second anti-obesity diet (3-5 of the normal diet required) and never to the third dietary (1-2 to 2-5 of the calculated normal diet) .

In many cases it is desirable to place such patients in an institution where they can be under more rigid supervision.

Together with regulation of the total quantity of food that is to be permitted the physician should also give instructions in regard to the distribution of this quantity over the different meals. Here the same factors must be considered as in cardiac disease. It is better to prescribe many small meals than few large ones. As a rule nothing need be eaten between early breakfast and midday dinner but a light lunch and nothing between dinner and supper but a few mouthfuls late in the afternoon in order to decrease the appetite for the two chief meals of the day to such an extent that the patient is not in danger of eating too rapidly or of eating too much at one sitting. In more advanced stages of the disease when the heart is beginning to grow weak it is best to insist on a light meal every two hours.