Unless particular reasons argue against its employment, fat is among all articles of food the most valuable in fattening cures. It owes its position to the property it possesses to a pre-eminent degree of representing a high caloric value (1 g = 9.3 cal.) in a small volume. Individuals who wish to undergo a fattening cure are almost without exception poor fat eaters and have frequently been so from childhood up. If they had not been bad fat eaters, or if they had not become so, it would not have become necessary to fatten them, for any individual who eats sufficient fat possesses at least an average minimum body weight (aside possibly from sufferers from certain diseases like diabetes, exophthalmic goitre, etc.). Frequently the small ingestion of fat is merely a matter of habit. Occasionally there is an aversion to fat, frequently based upon the prejudice that fat is under all circumstances difficult to digest. There are unfortunately many health cranks who judge everything that is offered to them in the way of food from the standpoint of its ready or difficult digestibility. They rarely utilize their personal experience as a criterion. The latter should be reckoned with somewhat, of course, in practice, although one must anticipate a tendency on the part of such individuals to deceive themselves. Generally the prejudice is based upon imagination, upon the dicta of other persons, so-called family traditions, or upon pseudo-scientific bits of information that have been picked up here and there. With rare exceptions, that must be occasionally conceded, all this is nothing, however, in reality but prejudice.

Individuals who must undergo a fattening cure rarely ingest spontaneously more than 100 g of fat.

I base this statement upon the great number of diet calculations that I have made. Under ordinary conditions 100 g of fat constitute a perfectly safe quantity. Voit's "Normal Diet" (for 70 kg of body weight with an average amount of labor) incorporated, as is well-known, aside from 118 g of albumen, only 56 g of fat with a maximum of 100 g when the individual was performing very energetic labor; hence there were derived from the fat only 520 to 930 calories. In addition, however, 500 g of carbohydrate were assumed to be present in this diet, representing 2050 calories. Voit arrived at this disproportion between fats and carbohydrates, because he performed his investigations among people who were used to an exceptionally large carbohydrate diet occupying an exceptionally large volume; for we mentioned above that 500 g of carbohydrate represent a volume of at least 2500 ccm. One should not base observations intended to be of general application upon individuals with abnormal habits. In cases, however, in which the consumption of carbohydrate food is materially reduced, as in the case of individuals whom we intend to fatten, the sum of 100 g of fat will be just sufficient, when added to the small amount of carbohydrate and the albumen ration, to aid them in maintaining the balance of nutrition.

The question now arises to what extent can fat be utilized in order to raise the value of the food above the level of the maintenance diet. According to my experience, one has no difficulty in increasing the fat ration up to 250 g per diem, so that the fat alone represents the respectable figure of 2325 calories. It is possible to go still higher, but then one must be prepared for occasional digestive disturbances that may retard the progress of the fattening cure for a number of days or (and this is much more to be feared) may frequently discourage the patient. In so far as I consider it advisable to accustom the patients to a diet that they can maintain for a long time, above all things after the termination of the cure proper, I am inclined to abstain from the beginning from an excessive increase of the fat intake. One should usually be content to bring the daily intake up to 200 to 250 g. When this is done the general diet more nearly represents a natural method of feeding, for 200 to 250 g of fat may very easily be concealed in the rest of the food. As soon, however, as the sum of about 250 g is exceeded, the selection, arrangement and preparation of the food must vary from the ordinary diet, and when this occurs difficulties arise that may not become manifest at once, but will certainly appear if this fat diet is continued for a long period of time. Consequently, under this plan, the permanency of the result becomes doubtful just as in the case of too abundant carbohydrate feeding (see above). One should never forget that the fattening cure proper, that is, the increase of the body weight from 6 to 10 kg during a period of systematic treatment extending over two months, is by no means the most important goal. Much more essential is the permanency of the result, and much more important is also the educational value of the fattening cure proper, for by it we attempt to teach the patients how they must eat in order to continue the strengthening process and to remain permanently strong. A fattening cure is a true course of education that these patients require. They must be educated to eat large quantities of fat. As soon as this result is assured, the danger of a relapse to a poor condition of nutrition becomes very slight.

The importance of the educational element in fattening cures cannot be sufficiently emphasized, and for this reason one has been in the habit for a long time of advising fattening cures to be carried out in a hospital or a sanatorium; for in all really difficult cases constant and continuous contact between the physician and the patient becomes necessary. Routine above all things and the following of a definite schedule are to be condemned. In each individual one must study separately how the caloric value of the food can be raised to the desired total, not only for the moment but permanently. Not only must the patient be instructed by the physician, but the physician should also learn from each patient. One of the main criticisms that has been formulated against various sanatoria is the fact that they lay too much emphasis upon the momentary result and not enough upon the educational factor and upon the after effect of the fattening cure.

No other article of food requires so careful an investigation of individual peculiarities in each patient as fat. It is essential to introduce large quantities of fat. One can almost say that to a certain extent the immediate result and by all means the permanent result in any fattening cure depends upon our ability to accustom the patient to take large quantities of fat. This applies particularly to early stages of pulmonary tuberculosis and to the mass of gastric and intestinal troubles that are treated by fattening cures. Late stages of gastric ulcer, of chronic constipation, of gastric and enteric neurasthenia constitute the principal candidates for fattening cures. The introduction of abundant quantities of fat as an established custom in pulmonary tuberculosis harks back to the days when the safety anchor of tuberculosis was sought for in codliver oil. In functional and in many organic diseases of the digestive canal, the introduction of large quantities of fat was only attempted much later. We live in an age that rapidly forgets, consequently it may not be amiss to remind my readers in this place that it was only my investigations in regard to the utilization of the food in gastric diseases and the investigations that I published jointly with C. Dapper that blazed the trail in this direction. Now-a-days we are afraid of abundant fat feeding in gastric and intestinal diseases only in cases suffering from true inflammatory processes about the stomach or the upper sections of the intestine, or in cases in which disturbances of the fat absorption are definitely demonstrable. It is clear that the introduction of fat becomes more difficult the more gastrointestinal disturbances predominate in the general disease picture.

As a rule it suffices in fattening cures to administer a definite fixed amount ("eiser nen Bestand") of fat-containing foods, that must be introduced in some way or another.

Merely as an example, not as a standard, the following combination may be given:

table 17

Together with the proteids and carbohydrates contained in a liter of milk and together with the caloric values incorporated in other foods added to the above, the highest caloric values that can be utilized at all in fattening cures may be reached on this basis. The amount of fat given in the above example is greater than is generally to be recommended (see above). By the addition of 300 cc of cream the fat intake reaches the high value of 268 g and very frequently it becomes necessary to omit the administration of so much cream, for there are many individuals with otherwise perfectly healthy digestive organs that are very susceptible to cream and suffer a considerable loss of appetite as soon as too much cream is given.

A list of articles of food containing much fat and that can be utilized in fattening cures will be found at the end of the first lecture.