I have emphasized above that in formulating regulations of a dietetic character intended to counteract obesity no definite schematic plan should be followed. Any one who has familiarized himself with the relations existing between caloric intake and energy output (see Vol. VIII), must understand what an infinitude of modifications may exist in the arrangement of an anti-obesity diet. The essential element always remains the reduction of the caloric intake below the "maintenance diet," and at the same time the introduction of a sufficient quantity of proteids. Within these limits the most manifold modifications are possible. As an example I may quote the so-called milk cure that has recently been recommended. Now, it has been known for a long time that exclusive milk feeding as a rule partakes of the character of a diet restriction, i.e., of a reduction cure. A liter of milk, as a rule, incorporates approximately 625 calories. An obese subject, like the individual illustrated in the example given above, would therefore require four liters of milk in order to maintain nutritive equilibrium. If milk constitutes the only article of diet it becomes very filling. The demand for food in most obese subjects can readily be satisfied by two liters, at most three liters, of milk, and on this diet he must lose flesh, because in the first case he receives only about in the second case only about of the value of his calculated maintenance diet. Whether it is practical, however, to proceed in this way remains another question. I judge reduction cures, as well as any other systematic method of feeding instituted for the purpose, for instance, of fattening thin subjects, or diabetics, etc., not only from the standpoint of temporary success but also, in particular, from the standpoint of their educational value. The patients should learn, in the course of their treatment, how to arrange their mode of life in the future; hence I have always considered it most expedient to adhere as closely as possible to the ordinary mode of life of each individual and to make changes and restriction in their common schedule appropriate to the particular object in view. If one proceeds in this way the results are apt to be more lasting than if a reduction cure by dieting is undertaken that stands in no relation whatsoever to the patient's ordinary habits nor to his future mode of life. Routine treatment according to a definite scheme or schedule fails properly to teach them the errors that they have committed in the past and that they must avoid in the future. Milk cures have become popular only within the last few months, and, nevertheless, I have already seen four patients who rapidly lost flesh while undergoing this cure, but promptly regained this loss as soon as they became tired of the milk; here a diet invariably had to be decided upon, after all, that more closely simulated their ordinary habits and that was formulated according to old and well-established principles.

What has been said in regard to this milk cure practically applies to other reduction diets that possess some semblance of originality, but that for this very reason are not permanent in their effects. I refer for instance to a strictly vegetarian diet. The latter incorporates abundant carbohydrate, holds little fat and little albumen, and is of a low total caloric value, at least in comparison to its bulk. Preference is given to this diet in Lahmann's institute and in other so-called Nature Cure sanatoria. It is, of course, self-evident that a considerable reduction of flesh can be secured by such a diet. While the patients are living under the strict rules of the institution everything proceeds favorably in the beginning; soon, however, the effect of the small albumen ration becomes manifest, and general weakness not infrequently develops later from such a regimen. Besides, patients fed in this way become accustomed to the ingestion of a diet that is altogether too voluminous, so that when they return home they find it difficult to curb their polyphagia, especially if the food either from carelessness or from a desire to render it more palatable is prepared with abundant fat; it is clear that under these circumstances they rapidly regain the flesh they had lost. Many cases, moreover, suffer permanent injury because their musculature grows weak and flabby and they become anaemic as a result of living for so long a time on a diet that is deficient in the proper amount of albuminous pabulum.

Some time ago I had the opportunity of studying the case of a Russian physician who on the basis of theoretic studies had constructed for his own use the following simple reduction diet :

table 5

For months this diet, with the addition of water, constituted his sole food; the result obtained was formidable, inasmuch as his weight became reduced from 121 kg. to 79 kg. He consulted me because of late he had noticed a general loss of strength. He did not want to abandon the method of feeding he had adopted, so I advised him to add 4 eggs daily to his diet in order to bring his low albumen intake up to about 110 g. and his total caloric intake up to about 1500. I saw him again several years later, and he expressed his gratitude to me for the advice I had given him, for he soon recovered his strength and permanently retained good general vigor. During all this time he continued to live on the same diet; his body weight finally fell to 72 kg., and, aside from slight fluctuations, thenceforth remained constant. In this case no doubt a "retardation of the metabolism" (see Vol. VIII) occurred, otherwise the scanty number of calories introduced could not have maintained the relatively high body weight of 72 kg. for so long a time. This physician was inclined, when I saw him last, to publish his method of dieting as an effective and commendable reduction cure. I have never been able to determine whether this was actually done. Recently I learned that he fell a victim to cholera last year. If the diet that this patient devised for himself had been a little richer in albumen (an improvement that could easily have been arranged) then no objections could have been formulated against it on general principles. The percentage of carbohydrate and fat corresponds approximately to my own recommendations given above. The loss of flesh must be very considerable. But it is very questionable whether a diet cure as heroic as this one would prove suitable for other patients, and I seriously doubt whether many patients would have the will power or the energy to live on a diet of this character, that closely resembles that of Nomad tribes, for any length of time.

Generally speaking, a diet system will fulfill its object as a reduction cure the less it is "original" and the more it corresponds in its general character to the diet that is generally eaten by each nationality.