Obesity

Bernhard Naunyn (born 1839) was the pupil of Lieberkiihn, Reichert, and von Frerichs. Though the author of a number of researches, they include no important discovery. His position as the foremost diabetic authority of the time rests upon his influence for the advancement of both clinical and experimental knowledge; upon his judgment, his teaching, and his pupils; upon the fact that from his great Strassburg school have come the soundest theories, the most fruitful investigations, and the most effective treatment. 

In birth, it is to be noted that Naunyn preceded Kiilz, and was only two years younger than Cantani. He came into this field in the pioneer period when the principle of dietetic management was generally recognized, but the average practice, especially in regard to severe cases, was still a mass of ignorance and inefficiency. As late as 1886, Naunyn stood as the champion of strict carbohydrate-free diet in a German medical congress where most of the speakers opposed it. As one of the few early German followers of the Cantani system, he maintained its feasibility and ultimate benefit, and locked patients in their rooms for five months when necessary for sugar-freedom. 

With experience, he gradually introduced modifications, until the rigid and inhuman method, which a majority of physicians and patients would never adopt, became a rational individualized treatment, with a diet reckoned according to the tolerance and caloric requirements of each patient. The work of various pupils requires mention in this connection. Important investigations of metabolism established the basis for this treatment, the most notable being that of Weintraud, who proved that, instead of having an increased food requirement, diabetics could maintain equilibrium of weight and nitrogen on a diet as low as or a little lower than the normal. Minkowski discovered with von Mering the diabetes following total pancreatectomy in dogs, and established the doctrine of the internal secretion of the pancreas, as well as the first clear conception of a dextrose-nitrogen ratio. After the early acetone investigations and Gerhardt's discovery of the ferric chloride reaction had failed to reveal the cause of coma, the Naunyn school accomplished almost the entire development of the subject of clinical acidosis in the following sequence. Hallervorden (1880) discovered the high ammonia excretion, confirming an earlier discredited observation of Boussingault. Stadelmann (1883) established the presence in the urine of considerable quantities of a non-volatile acid supposed to be acrotonic, correlated the condition with Walter's previous acid intoxication experiments, and theoretically suggested the treatment with intravenous alkali infusions. Minkowski proved the excreted acid to be /8-oxybutyric, and demonstrated the presence of this acid in the blood and a diminished carbon dioxide content of the blood. He, also Naunyn and Magnus-Levy, applied the alkali therapy in practice, and the latter carried out chemical and metabolism studies which made him the recognized authority in this field. Naunyn introduced the word acidosis, saying in definition ( (4), p. 15): "With this name I designate the formation of /8-oxybutyric acid in metabolism." The Naunyn school have consistently maintained that this acidosis is an acid intoxication in the sense of Walter's experiments. They demonstrated striking temporary benefits from the alkali therapy, particularly in diminishing the danger of the change from mixed to carbohydrate-free diet; but the practical results were never equal to the theoretical expectations. With Naunyn, also, acidosis became the principal criterion of severity for the clinical classification of cases. As regards other theories, the Naunyn school have upheld the deficient utilization as opposed to the simple overproduction of sugar in diabetes. They have clearly recognized the necessary distinction between diabetes and non-diabetic glycosurias." Naunyn was next after Klemperer to recognize clinical renal glycosuria. Though observing that "the course of the disease is as variable as can be conceived," he nevertheless upholds the essential unity of diabetes, finding in heredity a link which often connects cases of the most varied types. In regard to the etiology, he considers that "it is certain that disease of the nervous system and of the pancreas can produce diabetes;" other causes seem more doubtful. The nervous disorder supposedly acts indirectly by setting up a functional disturbance in the pancreas or other organs directly concerned. Underlying everything in most cases is, in his opinion, the diabetic "Anlage" or inherited; constitutional predisposition. Naunyn has particularly supported; the conception of diabetes as a functional deficiency, to be treated by sparing the weakened function. He wisely emphasized the importance of doing this at as early a stage as possible, before the tolerance has been damaged and the glycosuria has become "ha- bitual." His plan of treatment is to withdraw carbohydrate gradually, giving large doses of sodium bicarbonate in cases with acidosis as ii, further precaution against coma. A brief increase of the ferric chloride ; reaction is not allowed to interfere with the program. When the glycosuria is successfully cleared up, the aim is if possible to place the patient on a Rubner diet, representing 35 to 40 calories; per kilogram of body weight and about 125 gm. protein, carbohydrate being gradually added and then kept at a figure safely below the tested tolerance. The views concerning exercise agree with those of previous authors; brisk walking, etc., is found beneficial; but overexertion is harmful, especially in severe cases; and some patients seem to do best on a rest cure. When sugar-freedom is not attained on simple withdrawal of carbohydrate, protein may be reduced as low as 40 to 50 gm. daily and the calories also diminished, since diabetics may remain in equilibrium on as little as 25 to 30 calories per kilogram. When necessary as a final resort, temporary under- nutrition may be employed; but prolonged under-nutrition or the loss of more than 2 kilos weight should be avoided. Loss of weight continuing over the third week of treatment requires adding carbohydrate and abandoning the attempt to stop glycosuria. Occasional fast-days are advised if necessary, but only when previous treatment has reduced the glycosuria below 1 per cent; otherwise their effect is indecisive. It is stated that such fast-days are practicable for even the severest cases, and heavy acidosis is not a contraindication; the ferric chloride reaction may diminish on a fast-day. Naunyn has not stated what limitations apply to the use of such occasional fast-days, but Magnus-Levy stipulates that they must never be more frequent than one in eight or ten days, and in very thin patients must be avoided altogether. 

Fasting is nowhere recommended as a treatment for coma by Naunyn. On the contrary, when restriction of diet produces really threatening symptoms, his plan is to add carbohydrate and give up the attempt to abolish glycosuria. Even the persistence of a very heavy ferric chloride reaction longer than two or three days is a signal for adding carbohydrate. The treatment for impending coma consists in maximal doses of bicarbonate and the free use of carbohydrates, especially milk. Naunyn had some conception of limiting the total metabolism, but meant by it only a bare maintenance diet, or the slight and temporary undernutrition mentioned above. Naunyn states that fat does not appreciably increase glycosuria; elsewhere that in very severe cases it may slightly increase glycosuria; Magnus-Levy that it never gives rise to glycosuria. Like others, Naunyn considers that fat is the chief food for the diabetic; that the introduction of fat is the most important art in diabetic cookery . He uses it to complete the full number of calories when other foods are restricted; this applies even to the severest cases on carbohydrate-free diet with strict limitation of protein, where accordingly much fat is given; his principal care is that the patient shall take enough of it; the only reason for limiting the quantity is the danger of indigestion , except when coma impends, in which case fats are replaced by carbohydrates, and butter is especially shunned because of its content of lower fatty acids. Even when sugar-freedom is attainable, certain cases are believed to show an inherent progressive downward tendency. Concerning patients emaciated down to 50 kilograms, with heavy ferric chloride reaction and the usual accompaniments, it is said: "In the face of these great difficulties and dangers, which accompany the energetic management of these very severe cases, the prospects of being successful in permanently removing glycosuria are in general not very great, and usually one will be content with a limitation of it which suffices to bring the patient into nutritive equilibrium, that is, down to 60 to 80 gm. sugar in 24 hours."

" This is commonly supposed to have been an intentional following up of the observations of Cawley, Bouchardat, and others. But according to Dr. A. E. Taylor (personal commumication) the epoch-making discovery was accidental. Dogs depancreatized for another purpose were in a courtyard with other dogs. Naunyn, perhaps mindful of the part played by insects in the history of diabetes, asked, 

"Have you tested the urine for sugar?" 

"No." 

"Do it. For where these dogs pass urine, the flies settle." 

 

Dr Edoardo Ughi – Italy -1886

THE CARNIVOROUS DIET IN GENERAL AND PARTIAL OBESITY

COMMUNICATION BY DR. EDOARDO UGHI Prof. of Propaedeutic Medical Clinic at the University of Parma

The method to be followed in the treatment of obesity is now the subject of lively discussion in Germany, where it appears that such an affliction is frequent due to abundant nutrition, and perhaps most of all due to the exaggerated consumption of beer. Three systems are now followed in the cure of corpulence, and each of them has valid supporters.

The first, and oldest, used without contest for many years, is that of Banting. It is based on the fact that one must eat much albumin, without starch and without fat. The exact prescription is as follows: in the morning 150 gr. of lean meat with bitter tea and 30-40 gr. of bread; at midday 150-180 gr. of lean meat with a small quantity of legumes, little wine, no beer, no farinaceous foods; in the evening 60-100 gr. of meat and later another 120 gr. In total about 170 gr. of albumin, 10 of fat and 80 of carbohydrates are administered.

The cure of Ebstein consists in giving fewer fats and carbohydrates than the body consumes, with the prescription of eating slowly and stopping at the first sense of fullness.

Oertel subtracts liquids as much as possible, with the aim of producing a desiccation of the body. He permits all foods, but in small quantity, so that the pre-existing substances must be consumed in part. He also recommends muscular exercises, both because much water is subtracted from the body through sweat, and because more fats are consumed and the respiratory muscles and heart are strengthened.

The cure of Schweninger, with which Prince Bismarck was cured, is identical to that of Oertel. He too permits all foods in small quantity, prohibits drinking during meals and prescribes muscular exercises. It cannot be denied that each of these methods is founded on good physiological arguments, and is not in disagreement with the laws that regulate material exchange. Therefore, it is no wonder that each of them is effective in achieving the goal, and is thus preferred by various authors. But objections have been raised against all of them.

It has been said that Banting’s cure should not be adopted, because it is poorly tolerated, and gives rise to gastro-enteric disturbances due to the large quantity of meat that must be introduced. Oertel’s cure is burdensome due to the thirst that must be suffered, and Ebstein’s is long and uncertain. It suffices, moreover, to read the debate that took place between these two authors and the various opinions expressed within the Medical Society of Leipzig, last year, by Wagner, Hoffmann, Heubner, Taube and others, to recognize how results and assessments vary. I therefore gladly take this occasion to bring to the attention of the medical public my not insignificant experience on the subject, having treated many sufferers of obesity over various years. I will thus be able to demonstrate the advantages of the exclusive carnivorous diet in obesity, and in general the tolerance that the organism presents for such a diet, which should therefore be more easily utilized even in other cases. It should be noted that I consider here, with many German authors, not only the general increase of fat in the organism as obesity, but also more specifically that limited to certain organs (heart), in such a way as to disturb their function and give the same phenomena as general obesity. I therefore distinguish between absolute and relative obesity.

1st Case. -- B.L. 30 yo, weighs 126 kg

1st Case. — B. L. aged 30, whose father died of apoplectic stroke and was very obese, is 1.88 m tall, weighs 126 kg, and suffers heart disturbances, without having any valvular defect: when climbing stairs, and walking at only a moderate pace, he is seized by strong shortness of breath; moreover this gentleman is affected by dyspepsia due to chronic catarrh of the ventricle. He habitually took two meals a day, a soup and a meat dish for breakfast, a soup and two dishes for dinner, plus 300 gr. of bread, and usually drank a liter and a quarter of wine and almost no water. I suspected that the aforementioned disturbances were caused by obesity and fatty infiltration of the myocardium. The weak and sometimes irregular pulse, the cardiac tones also weak and not very clear, and the arrhythmia that was observed, confirmed me more in my suspicion, so I subjected him to the following dietetic cure: For each day: lean meat from 700 to 900 gr., broth 300 gr., a bottle of wine, and when he ate a smaller quantity of meat, I allowed two or three eggs. I also prescribed that the individual maintain his habits strictly, that is, to always do that exercise to which he was accustomed, not to exert himself more than usual and to drink the usual quantity of water, etc. In five months of practicing these dietetic and hygienic prescriptions, his body weight decreased by 22 kg, that is, it went to 104 kg; the shortness of breath and heart disturbances disappeared, the conditions of digestion improved. For two years now he has returned to his habitual regimen, and his weight oscillates between 106 to 108 kg.

2nd Case. – G.L. 96.5 kg to 88 kg and maintained two years

2nd Case. — G. L. complains of dyspepsia, shortness of breath and inability to resist in the work of grocer; he is 1.73 m tall, weighs 96.500 kg; apart from obesity, I found no sick organ, except for a slight gastric catarrh due to excessive use of wine. The individual is accustomed to taking two meals a day, and in total took a soup, two dishes (sometimes meat, sometimes vegetables), 300 gr. of bread, and drank 2 or 2½ liters of wine, very little water and often made no use of it. I subjected him to the identical cure of the previous case, because in this case too I believed that obesity was the principal cause of the shortness of breath and inability to resist at work. The individual maintained his habits in work, walking, etc. After three months of said cure the weight descended to 87 kg, the shortness of breath and dyspepsia disappeared, and the individual could frankly resist, without need of tiring himself, his occupations. Two years have already passed since the cure, and the weight has oscillated between 87 to 88½ kg.

3rd Case. – Mr. U. O. 87.5 kg to 73 kg over 5 months

3rd Case. — Mr. U. O., 1.69 m tall, weighs 87½ kg, suffers no ailment, except for slight dyspnea when climbing stairs. The individual takes three meals a day: in total he eats a soup, 450 gr. of bread, 300 gr. of meat, and drinks a liter of wine, a black coffee and little or no water. For 5 months he takes 200 gr. of broth, 700 gr. of meat, two or three eggs, and drinks a liter of wine, as usual, nothing or almost no water, does not modify his occupations and habits at all. At the beginning of this cure he felt weakened, afterwards he noticed no ailment. In these five months the weight descended to 73 kg; a year has passed since the end of the cure, and now he weighs 78 kg. Currently he has no longer the slightest trace of shortness of breath.

4th Case. – C. D. 45 yo, 102 kg to 89 kg over 4 months

4th Case. — C. D. aged 45, 1.66 m tall, weighs 102 kg, and suffers from shortness of breath, frequently also from dizziness. The cardiac impulse is weak, as are the cardiac tones; after prolonged efforts the individual remains very exhausted, and then a slight degree of cyanotic color is seen on the lips, face and also hands: it is in these moments that he complains of strong dizziness, to free himself from which the individual resorts to bloodletting. I believed that following fatty infiltration of the myocardium, systolic insufficiency had arisen, hence the cyanosis, shortness of breath, dizziness due to venous stasis. This man eats moderately: a soup, 300 gr. of meat, 350 gr. of bread, drinks two liters of wine. For 4 months he abandoned the soup and bread, and reduced the wine by one liter. In this time, he took a broth of 300 gr., meat 750 to 800 gr., some eggs and one liter of wine. During the cure he did not modify his habits in working, walking, etc. at all. When the cure was finished, the weight went to 89 kg, the shortness of breath diminished, the cyanosis only occurs at some moments and in slight degree, the dizziness is much less frequent and lighter.

5th Case. – B. Appio, 35 yo, 98 kg to 88 kg

5th Case. — B. Appio aged 35, 1.60 m tall, weighs 98 kg, suffers very much from shortness of breath, somnolence, cyanosis, dizziness, sleeps a very agitated and interrupted sleep, has an irritating cough with frothy serous expectoration, and has strong edema in the lower limbs: this man finds himself almost unable to discharge his duties as a tobacco seller. In this man are found in the maximum degree all the phenomena of the previous case, and certainly they arose through the same modality, except that in B. there is severe edema in the lung, legs and perhaps also in the brain, given the disturbances already mentioned and the cries he emits at night. The examination of the heart does not permit admitting any valvular defect, only the 2nd tone of the pulmonary is found anomalous, which is much reinforced relative to the first; a fact that is explained taking into account that there is strong congestion and edema in the lung. B. eats much soup (two or three portions), 300 gr. of bread, little meat, drinks a very large quantity of water and only half a liter of wine per day. I had the individual continue for three months to take from 700 to 800 gr. of meat, some eggs, a broth of 200 gr. and his usual quantity of wine (½ liter) and water. Weighed after this time, he is no more than 88¼ kg. Now he is well; the edema in the legs and lung has disappeared, moreover all the other facts have almost dissipated, except for a slight degree of shortness of breath. The cure ended at the end of November last, and until today the patient has remained in the conditions just described. I note that this man led a sedentary life before the cure, and during the same.

6th Case. – B. G. 42 yo, 110 kg to 99 kg

6th Case. — B. G. aged 42, 1.85 m tall, weighs 110 kg, suffers from dyspepsia and has impeded movements; has dilatation of the ventricle. This subject eats a kg. of bread per day, in addition to a very abundant soup and a dish; drinks 2 or 2½ liters and little water. For three months I arranged so that the individual did not change habits, did not walk more than usual, did no work more than usual, and always drank the same quantity of water, which he was accustomed to in the past. In these three months he ate a kg. of meat and two eggs per day, and drank a liter and ¼ of wine, 300 gr. of broth per day; after this term he weighed 99 kg. During the cure he improved in digestion, and movements became easier. Having returned to the habitual diet for a year, he now weighs 102.500 kg. The phenomena of altered digestion have renewed.

7th Case. – B. Lawyer, enormously obese loses at least 15 kg

7th Case. — B. Lawyer, 1.68 m tall, is enormously obese, orthopneic, edematous (in the lower limbs); had several attacks of asystole, and due to these serious facts had to abandon his profession and go to the city. Due to the gravity of the aforementioned symptoms, it was not possible for me to establish a physical examination of the circulatory center and therefore a certain diagnosis. This gentleman was always a good eater and a discrete drinker, but I could not say the quantity of food and drink he introduced daily. I saw this gentleman only once, not being his doctor, and I advised him to the identical cure of the first two cases. After about three months of such cure, I learned that all the imposing symptoms had disappeared, but that some shortness of breath remained. A short time ago I met the aforementioned gentleman and saw that he must have decreased in weight by at least 14 or 15 kg. I hope to be able to know where he currently resides and thus specify many of the aforementioned facts.

8th Case. – B. M., 65 yo, 90 kg to 83 kg

8th Case. — B. M. aged 65, 1.55 m tall, weighs 90 kg, and is almost unable to walk due to strong dyspnea. This lady leads a sedentary life; takes daily a coffee and milk with bread, a soup, two dishes (more often meat), 200 gr. of bread and drinks a bottle of wine and very little water. I did not want her to change her habits, except in food; during the cure she therefore led an extremely sedentary life. For two months she continued to take daily 700 to 800 gr. of meat, some eggs, two broths (400 gr. in total), and her habitual bottle of wine. After this time the lady weighed only 83 kg, and walked, moderately, without shortness of breath.

9th Case. – Mrs. Z. G., 32 yo, 92 kg to 84 kg

9th Case. — Mrs. Z. G. aged 32, daughter of an extremely fat mother, weighs 92 kg, has no serious disturbance, only feels heavy, and cannot therefore attend to her affairs with that agility to which she was accustomed in past years. At night she is almost always seized by tingling in the limbs on which she lies. She uses mixed food, but prefers vegetables, and drinks a bottle of wine per day and little water. For two months I had her completely abandon vegetable foods, and allowed her a broth of about 200 gr., 700 to 800 gr. of meat, two eggs and her usual wine. This lady was always very active, and during the cure did not modify her habits at all. Weighed after the cure was finished, she was only 84 kg; she acquired complete freedom of movement, and the tingling completely disappeared.

10th Case. – G. Adele, 39 yo, 95 kg from much use of vegetable food, down to 86 kg

10th Case. — G. Adele aged 39; her father is very obese, and she weighs 95 kg, and for a long time has had shortness of breath, cough, edema in the lower limbs. This lady makes much use of vegetable food, and hardly eats meat except in winter, drinks almost a bottle of wine every day. Having made a delicate examination of the heart, I could find nothing morbid, only the tones were weak, and the radial pulse also weak and small. To explain the phenomenological syndrome, in addition to taking into account the general adiposity, I also had to resort to fatty infiltration of the myocardium and the diminished strength of the same due to this fact. For 70 days continuously she took 700 to 800 gr. of lean meat (for the previous cases too I always gave lean meat), a pair of eggs, a broth of 200 gr., and the usual quantity of wine. During this cure she did not change her habits in any way. Weighed after the cure, she was no more than 86 kg, and her sufferings had almost totally disappeared.

I add to my cases the following treated by my esteemed friend Dr. Guido Musiari.

11th Case. – Mr. Cotti Giuseppe of Noceto, 40 yo, 137 kg to 97 kg

11th Case. — Mr. Cotti Giuseppe of Noceto, aged 40, 1.88 m tall, weighs 137 kg; is not dyspneic, and it is surprising to see much agility preserved in his movements. This gentleman eats and drinks much, following which a strong dilatation of the ventricle was established. Three years ago, Mr. Cotti ingested a very strong quantity of ice-cold water, and immediately afterwards was seized by an epileptiform attack. The doctor thinking that the attack had arisen from a reflex fact (dependent on the ventricle), advised this man to follow a predominantly carnivorous diet, allowing only a very small quantity of bread, a small soup, meat at will, some eggs and a moderate quantity of wine; the patient has continued for almost three years to put into execution the prescribed diet, and in this time his body weight has diminished by 40 kg, that is, he weighs 97 kg. I note that this man used potassium bromide for a long time, the epileptiform attack still repeating from time to time, but Cottis mental faculties are not altered at all.

SUMMARY TABLE [Table showing 11 cases with columns for: Case number, Initial body weight, Diet used, Duration of cure, Final body weight, and Observations. The table details the results of the carnivorous diet treatment for each patient, showing significant weight loss and improvement in symptoms across all cases.]

From this exposition results:

1) 1st That the exclusive, or almost exclusive, carnivorous diet was well tolerated in all cases, and never gave rise to disturbances; indeed, the dyspeptics improved greatly in their sufferings, and the individuals, after becoming accustomed to it, suffered from flatulence when they returned to the ordinary diet.

2) 2nd That the carnivorous diet always produced a notable diminution of body weight, with improvement of the general state.It especially served to dissipate shortness of breath and all phenomena related to obesity of the heart and weakness of the respiratory muscles, for which Oertel so much vaunts his own method. Finally, I must add the singular observation, that in many of my patients the skin acquired through the use of meat a more intense color than it had before. Some of the men confessed to me that before the cure they also had impotence or almost impotence in coitus; after they became thin, they regained their virile potency.

Physiology gives us reason for these results, and supports them with its laws.

It is true that man can make use of all aliments, but it must be recognized however that the gastro-enteric tube is more conveniently conformed for animal foods, as in carnivores. Therefore, the carnivorous diet must be suitable for him. This moreover satisfies very well the norms to which any system of cure for corpulence must correspond, that is:

1st That the individual does not consume fats, or bodies capable of forming them, in quantity greater than that necessary for the maintenance of the body.

2nd That the individual consumes a part of the fat accumulated in the organism.

In the cases we have reported, the individuals consumed 700 gr. of lean meat per day, with slight addition of wine and other substances.

If we calculate with Voit that an adult man must, on average, introduce with food 18.3 gr. of nitrogen, in the form of albumin, and in total 328 gr. of carbon, the 700 gr. of meat are truly more than sufficient to cover the loss of nitrogen; indeed they give 23.81 gr. of nitrogen, instead of 18.3, but are totally insufficient to supply the 328 gr. of carbon. In fact, according to Voits calculations (Hermanns Handbuch der Physiologie, Bd. VI, pag. 407), it would be necessary for this purpose to eat 2620 gr. of lean meat. Let us also put in the calculation about 70-150 gr. of alcohol, contained in the wine consumed by these individuals, which, as was demonstrated by Albertoni and Lussana (On alcohol, on aldehyde and on wine ethers. Lo Sperimentale 1874), and recently repeated ad litteram by Bohland, copying the work of our compatriots without remembering it, burns almost entirely in the organism, and gives CO₂ and H₂O; nevertheless there always remains a notable deficit in the combustible carbon introduced, that is about half of the necessary, which must be covered by the fat previously accumulated in the organism, which is consumed, thus producing a notable diminution of body weight. Some of my patients did not truly show an increase beyond the ordinary in body weight and a large general deposit of fat, but instead showed well manifest the phenomena dependent on abnormal deposit of fat within the heart and respiratory muscles, whence shortness of breath and other related symptoms. Oertel justly calls attention to such a condition, and insists on the fact that his cure serves to dissipate it. I am pleased to note here that also in the cases reported by me a happy outcome was always obtained with the carnivorous diet. Regarding etiological conditions, heredity often plays a role in my patients. Few of them made use of truly superabundant food, although they belonged to the well-to-do class and had a certain alimentary budget of luxury. But in face of daily observation, that many persons with a luxury budget much greater than that of my patients, and not all of them, do not become obese, one is forced to admit for the development of such an affliction a particular disposition to the formation of fat from albuminoids and carbohydrates. It results finally that meat alone, when there is fat to burn, suffices very well to maintain life for months.

"Sir, - On Friday, January 8th, I read the account of Dr. Salisbury's treatment in the Pall Mall Gazette, and determined to try the effect of it in my own case. Seven years ago, I weighed 11 st. 12 lbs. (height, 5 ft. 9 in.), and when I trained for my college-boat I always lost five pounds. A month ago, I weighed 14 st., so I was at least two stone above my weight. If any of my lean brethren wish to know how I felt, let them put on a top coat with two stone of shot stowed away in the pockets, and wear it for a single day. When my friends congratulated me on my aldermanic appearance, their compliments were as gall and wormwood to my soul. If they had felt as I did, that the hills of life were growing steeper, and that the pleasure of living was contracting in a daily narrowing circle, they would have condoled with instead of congratulated me.

For the last six weeks, I have lived on lean meat and hot water, or its equivalent, and yesterday I weighed 13 stone. I have taken a pint of hot water (130° Fahr.) at 7 A.M.; a pint of "schoolroom-tea" with a squeeze of lemon in it at 11.30 A.M.; the same at 3.30 or 4 P.M.; and a pint of hot water (130° Fahr.) at 10 P.M.; a pound of beefsteak at 8.30 A.M.; a pound and a quarter at 1.30 P.M.; and a pound at 6.30 A.M. This has been hot, but preferably cold, and has been varied with hare, chicken, etc.

The result is this. I am a stone less in weight; I am six inches less in girth; my gouty "heirlooms," in the shape of "hereditary deposits," have disappeared; my flatulent indigestion has vanished; my mental and bodily activity have doubled; I spoke on Thursday for an hour with less effort than I did in December for ten minutes; I sleep for seven hours without moving; I can wear gloves and shoes a size smaller; I have lost my tendency to catch cold; my muscles are daily hardening; my kidneys are doing their duty nobly; my figure is altering so rapidly that my tailor is in despair, but I am triumphant.

When I have completed the course, if you will spare me room, I will finish my tale, and relate the lessons I have learnt in dietetics and therapeutics during the experiment. - Yours faithfully, Ben Rhydding, Leeds. JOHN FLETCHER LITTLE."

Diet. — Our injunctions to-day aro thoso of Sydenham : " Let the patient est food of easy digestion, eiich aa voal, mutton, and the like, and abstain from all sorts of fruit and garden stuff." The carbohydrates in tho food should be reduced to a minimum. Under a strict hydrocarbonaceous and nitrogenous regimen all casc«are benefited and some arc cured. The most minute and specific instructions should be given in each case, and the dietary arranged with scrupulous care^

 It is of the first importance to give the patient variety in the food, otherwise the loathing of certain essential articles becomes intolerable, and too oft«u tho patient gives up in diegiiet or despair. It is wcl), perhaps, not to attempt the absolute exclusion of the carbohydrates, but to allow a small proportion of ordinary bread, or, belter still, as containing less starch, potatoes. It is beat gradually to cnforoe a rigid system, cutting oH one article after another. Tho following is a list of articles which diabetic patients may take :

1.  Liquids; Soups — ox-tail, turtle, bouillon, and other clear soops 

2. Lemonade, coffee, tea, chocolate, and cocoa; these to be taken without sugar, but they may bo sweetened with saccharin. 

3. Potash or soda water, and the Apoltinatis, or the Saratoga Vichy, and milk in moderation, may be used. 

4. Of animal food : 

• Fish of all sorts, salt and fresh, 

• butcher's meat (with the exception of liver), 

• poultry, 

• and game. 

• Eggs, 

• butter, 

• buttermilk,

•  curds,

•  and cream cheese. 

• Of bread : gluten and bran bread, and almond and coconut biscuits. 

• Of vegetables: Lettuce, tomatoes, spinach, chiccory, sorrel, radishes, water-cress, mustard and cress, cucumbers, celery, and endives. Pickles of various sorts. 

5. Fruits : Lemons, oranges, and currants. Nuts are, as a rule, allowable 

Among prohibited articles are the following : 

1. Thick soups, liver, crabs, lobsters, and oysters; though, if the livers are cut out, oysters may be used. 

2. Ordinary bread of all sorts (in quantity): rye, wheaten, brown, or white. 

3. All farinaceous preparations, such as hominy, rice, tapioca, semolina, arrowroot, sago, and vermicelli. 

4. Of vegetables : Potatoes, turnips, parsnips, sqimslies, vegetable marrow of all hinds, beets, corn, artichokes, and asparagus. 

5. Of liquids: Beer, sparkling wine of all sorts, and the sweet aerated drinks. 

The chief difficulty in arranging the daily menu of a diabetic patient is the bread, and for it various substitutes have been advised — ^bran bread, gluten bread, and almond biscuits. Most of these are unpalatable, and the patients weary of them rapidly. Too many of them are gross frauds, and contain a very much greater proportion of starch than represented. A friend, a distinguished physician, who has, unfortunately, had to make trial of a great many of them, writes : 'That made from almond flour is usually so heavy and indigestible that it can only be used to a limited extent. Gluten flour obtained in Paris or London contains about 15 per cent of the ordinary amount of starch and can be well used. The gluten flour obtained in this country has from 35 to 45 per cent of starch, and can be used successfully in mild but not in severe forms of diabetes." ' Unless a satisfactory and palatable gluten bread can be obtained, it is better to allow the patient a few ounces of ordinary bread daily. The " Soya " bread is not any better than that made from the best gluten flour. As a substitute for sugar, saccharin is very useful, and is perfectly harm- less. Glycerin may also be used for this purpose. It is well to begin the treatment by cutting off article after article until the sugar disappears from the urine. Within a month or two the patient may gradually be allowed a more liberal regimen. An exclusively milk diet, either skimmed milk, buttermilk, or koumyss, has been recommended by Donkin and others. Certain cases seem to improve on it, but it is not, on the whole, to be recommended.

"A fat person, at whatever period of life, has not a sound tissue in his body: not only is the entire muscular system degenerated with the fatty particles, but the vital organs--heart, lungs, brain, kidneys, liver, etc.,--are likewise mottled throughout, like rust spots in a steel watch spring, liable to fail at any moment. The gifted Gambetta, whom M. Rochefort styled the fatted satrap died--far under his prime--because of his depraved condition; a slight gunshot wound from which a clean man would have speedily recovered ended this obese diabetic's life. Events sufficiently convincing are constantly occuring on both sides of the Atlantic; every hour men are rolling into ditches of death because they do not learn how to live. These ditches have fictitious names--grief, fright, apoplexy, kidney troubles, heart disease, etc.,--but the true name is chronic self abuse."

 

Fortunately there is a considerably greater apprehension in the public mind now than a few years ago as to the evils of growing fat. The writings of Mr. Banting, an enthusiastic layman who was greatly helped by a reduction of obesity, and whose interest in his fellow men prompted him to make as widely known as possible some thirty years ago his method of cure, has done much to dispel dense ignorance concerning this topic; and in more recent years the illness of Bismarck, and his restoration through the reduction of his obesity, was also a great help to spread knowledge on this most important subject. 

The exciting cause of obesity is the ingestion of more food that the system requires, together with the weakening of the excretory organs, which results in the failure of the system to adequately throw off its waste matter. But the profound and primal cause of obesity will one day be recognized to be the use of cereal and starch foods. An obese person weighing two, four or six stone, twenty-five, fifty, or eighty pounds, or even a still larger amount, more than is natural, may be given a diet of flesh with water with or without the addition of starchless vegetables, as lettuce, watercress, tomatoes, spinach, and the like, excluding bread, pulses and potatoes, and the patient will be gradually but surely reduced to his normal weight. As soon, however, as the patient returns to his usual diet of bread and potatoes he straightway begins to increase in weight; and while an obese patient can easily be reduced eight pounds per month when placed upon a flesh diet, he will gain fully this much or more upon returning to a free use of bread and starch vegetables. If this patient who has been reduced, and who has again developed obesity, is persuaded to again adopt the exclusive flesh diet, again the reduction is sure to take place; and in the course of our practice this process has been repeated among many patients, and in a few a reduction and return to flesh has been repeated three times. It is plain from such demonstrations that without starch foods corpulency would not exist. Chemically starch foods are chiefly carbon; adipose tissue is also carbon, and it would naturally be expected that a diet of oil and the fat of animal flesh would contribute quite as much to obesity as bread and starch foods. But experience proves that such is not the case. The reason for this is not, in the present state of science, understood; it will likely be found in the fact that starch foods undergo a complicated process of digestion, whereas oils require only emulsion to render them assimilable by the system. 

The courage and strength of conviction possessed by the average family doctor is curious to behold. It will be found to be inversely to the ratio of his knowledge. The less conversant he is with this malady the greater confidence he seems to have in his opinions. During the years that we were in practice some hundreds of patients came to us for assistance in this trouble, a large number of whom were under the control of their family physician. Many of these patients came in defiance of the express orders of their physicians; and while they had assumed courage enough to disobey their orders and come to us, they needed much encouragement to enable them to proceed with any confidence. They were usually told by their medical advisers that in them it was natural to be stout, that they had "better leave well enough alone," and the direst results were prophesied in the event that they had the temerity to proceed. In point of fact these patients quite invariably experienced nothing but the happiest results. many of them came out of an interest in their personal appearance; finding their figures destroyed and their beauty going, they desired restoration to their youthful form and feature. Others, again, were annoyed at clumsiness in getting about, shortness of breath in climbing stairs, and the general awkwardness and inconvenience that result from this "too, too solid flesh." Only a small proportion of these patients came from a knowledge that obesity is a disease, that it encourages other states of inflammation and other diseases, and that its reduction is a great aid in the return of health. But while thees patients as a rule did not come to us with this expectation, it was common for them to testify to geat benefits that had resulted from their treatment. These benefits were quite frequently greater than the patient would readily admit or remember. It was our custom, with all patients beginning treatment, to take the name, age, height, weight, and a list of the infirmities, if any, from which they were suffering. These details were elicited by a series of questions, and the answers duly recorded. Out of sight out of mind is the old adage; and human beings are fortunately so conditioned that when their aches and pains have taken flight they forget not infrequently that they were ever present. many of these patients would have stoutly denied the benefit rendered but for the diagnosis taken at the beginning of treatment, and a reference to wich only would convince them of the coniditon they had been in.